Cycle 1
Health 2025-05-15 · Fire 2025-05-15
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fayette, MS
Jefferson County Nursing Home
3-star overall rating with 4-star inspections with 4 recent health deficiencies
910 Main Street, Fayette, MS
(601) 786-3888
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
45
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-04-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.61
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
3.13
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
4.67
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
4.03
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
4.85
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,931
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.95
Composite VBP score used to determine payment impact.
Payment multiplier
1.0076
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.55
Baseline 18.92% · Performance 45.10% · Measure score 4.55 · Achievement 4.55 · Improvement 0
Adjusted total nurse staffing
6.04
Baseline 5.49 hours · Performance 4.80 hours · Measure score 6.04 · Achievement 6.04 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.86% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 20.69% · Lower 95% interval 7.85% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.66 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 75.76% |
95.27%
19.5 pts worse
|
Numerator 25 · Denominator 33 |
| Falls with major injury | 6.06% |
0.77%
5.3 pts worse
|
Numerator 2 · Denominator 33 |
| Discharge self-care score | 27.27% |
53.69%
26.4 pts worse
|
Numerator 6 · Denominator 22 |
| Discharge mobility score | 45.45% |
50.94%
5.5 pts worse
|
Numerator 10 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 3.03% |
2.29%
0.7 pts worse
|
Numerator 1 · Denominator 33 · Adjusted rate 1.65% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 39.06% |
8.2%
30.9 pts better
|
Numerator 25 · Denominator 64 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 27.27% |
56.45%
29.2 pts worse
|
Numerator 6 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.9 |
2.4
1.5 pts worse
|
1.9
2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.9 · Observed 4.0 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.2 |
2.9
2.3 pts worse
|
1.8
3.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.2 · Observed 4.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.0%
3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
3.2%
2 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.5% · Q4 2.4% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.6%
1.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.4% |
6.1%
4.7 pts better
|
5.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 1.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.3% |
24.4%
0.9 pts worse
|
19.6%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 22.9% · Q3 28.9% · Q4 26.3% · 4Q avg 25.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.5% |
23.4%
1.1 pts worse
|
16.7%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 30.8% · Q3 29.6% · Q4 21.4% · 4Q avg 24.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.5% |
22.8%
4.7 pts worse
|
16.3%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.5% |
20.6%
11.9 pts worse
|
14.9%
17.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.7% · Q2 33.3% · Q3 20.7% · Q4 29.0% · 4Q avg 32.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.5%
0.3 pts better
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 1.5% · Q4 1.5% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
2.5%
About the same
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 8.6% · Q3 0.0% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.2% |
21.4%
14.2 pts better
|
19.8%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 3.0% · Q3 7.6% · Q4 0.0% · 4Q avg 7.2% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
6.9%
2.8 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 2.0% · Q3 4.6% · Q4 5.5% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.3% |
87.9%
0.6 pts worse
|
81.7%
5.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 87.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.4% |
15.3%
2.1 pts worse
|
12.0%
5.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.4% · Observed 20.0% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 10.7% |
2.6%
8.1 pts worse
|
1.6%
9.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 10.7% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 40.6% |
27.9%
12.7 pts worse
|
23.9%
16.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 40.6% · Observed 46.7% · Expected 27.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-25 · Fire 2024-01-25
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-12-29 · Fire 2021-12-29
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-15
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-30
E · Potential for more than minimal harm
2024-01-25
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-25
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-01
D · Potential for more than minimal harm
2021-12-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-02-15
D · Potential for more than minimal harm
2021-12-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-02-15
Penalties and ownership
What sits behind the stars
Ownership
Jefferson County Nursing Home
5% Or Greater Direct Ownership Interest · Organization
Brinkley, Marilyn
Operational/Managerial Control · Individual
Buck, Brenda
Operational/Managerial Control · Individual
Wyatt, Ladonna
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Claiborne County Senior Care
Port Gibson, MS
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Meadville Convalescent Home
Meadville, MS
3-star overall rating with 3-star inspections with 7 recent health deficiencies
#3
Natchez Rehabilitation And Healthcare Center
Natchez, MS
3-star overall rating with 3-star inspections with 4 recent health deficiencies
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