Jackson, MS

Lakeland Community Care Center

2-star overall rating with 2-star inspections with $8,424 in total fines with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

3680 Lakeland Lane, Jackson, MS

(601) 982-5505

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

105

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Norbert Bennett & Donald Denz

Operator or chain grouping

Approved since

1989-06-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

29 facilities

Chain averages 2 overall / 2 health / 3 staffing / 2 quality stars

Changed ownership

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

0.40

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.03

Licensed practical nurse staffing · state 1.10 · national 0.87

Aide hours / resident day

2.36

Nurse aide staffing · state 2.48 · national 2.35

Total nurse hours

3.79

All reported nurse hours · state 4.21 · national 3.89

Licensed hours

1.43

RN + LPN hours · state 1.73 · national 1.54

Weekend hours

3.17

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.25

Weekend registered nurse coverage · state 0.37 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

0.47

CMS adjusted RN staffing hours

Adjusted total hours

4.48

CMS adjusted total nurse staffing hours

Case-mix index

1.16

Higher values indicate more complex resident acuity

RN turnover

60%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

62%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,942

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

14.6

Composite VBP score used to determine payment impact.

Payment multiplier

0.9814

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 19.64% · Performance 23.29% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

3.80

Baseline 6.87% · Performance 6.70% · Measure score 3.80 · Achievement 3.80 · Improvement 0.44

Total nurse turnover

0.17

Baseline 76.56% · Performance 73.08% · Measure score 0.17 · Achievement 0 · Improvement 0.17

Adjusted total nurse staffing

1.86

Baseline 3.91 hours · Performance 3.61 hours · Measure score 1.86 · Achievement 1.86 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.47%	10.72% 1.8 pts worse	No Different than the National Rate · Eligible stays 138 · Observed rate 14.49% · Lower 95% interval 9.18%
Discharge to community	53.8%	50.57% 3.2 pts better	No Different than the National Rate · Eligible stays 134 · Observed rate 47.01% · Lower 95% interval 44.17%
Medicare spending per beneficiary	0.86	1.02 0.2 pts better
Drug regimen review with follow-up	50%	95.27% 45.3 pts worse	Numerator 45 · Denominator 90
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 90
Discharge self-care score	33.9%	53.69% 19.8 pts worse	Numerator 20 · Denominator 59
Discharge mobility score	13.56%	50.94% 37.4 pts worse	Numerator 8 · Denominator 59
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 90 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.7%	7.12% 0.4 pts better	No Different than the National Rate · Eligible stays 71 · Observed rate 5.63% · Lower 95% interval 3.96%
Staff COVID-19 vaccination coverage	0.67%	8.2% 7.5 pts worse	Numerator 1 · Denominator 149
Staff flu vaccination coverage	19.87%	42% 22.1 pts worse	Numerator 30 · Denominator 151
Discharge function score	20.34%	56.45% 36.1 pts worse	Numerator 12 · Denominator 59
Transfer of health information to provider	89.66%	95.95% 6.3 pts worse	Numerator 26 · Denominator 29
Transfer of health information to patient	77.55%	96.28% 18.7 pts worse	Numerator 38 · Denominator 49
Resident COVID-19 vaccinations up to date	16.13%	25.2% 9.1 pts worse	Numerator 5 · Denominator 31

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.9	2.4 1.5 pts better	1.9 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.5 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.1	2.9 1.8 pts better	1.8 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	96.6%	95.7% 0.9 pts better	93.4% 3.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 94.0% · Q2 96.8% · Q3 98.5% · Q4 97.1% · 4Q avg 96.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	97.2%	97.0% 0.2 pts better	95.5% 1.7 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 97.2%
Percentage of long-stay residents experiencing one or more falls with major injury	1.9%	3.2% 1.3 pts better	3.3% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 1.5% · Q4 2.9% · 4Q avg 1.9% · 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	4.4%	6.1% 1.7 pts better	5.4% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.9% · Q3 3.1% · Q4 4.5% · 4Q avg 4.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	27.0%	24.4% 2.6 pts worse	19.6% 7.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.7% · Q2 29.3% · Q3 21.9% · Q4 25.8% · 4Q avg 27.0%
Percentage of long-stay residents who received an antipsychotic medication	12.6%	23.4% 10.8 pts better	16.7% 4.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 14.0% · Q3 10.9% · Q4 12.5% · 4Q avg 12.6% · 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	33.8%	22.8% 11 pts worse	16.3% 17.5 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 33.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	20.3%	20.6% 0.3 pts better	14.9% 5.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 25.8% · Q3 19.4% · Q4 22.7% · 4Q avg 20.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.1%	1.5% 0.6 pts worse	1.0% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.4% · Q3 3.4% · Q4 1.1% · 4Q avg 2.1% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.4%	2.5% 2.1 pts better	1.7% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	15.8%	21.4% 5.6 pts better	19.8% 4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 9.9% · Q3 13.0% · Q4 23.7% · 4Q avg 15.8%
Percentage of long-stay residents with pressure ulcers	10.4%	6.9% 3.5 pts worse	5.1% 5.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 13.0% · Q3 11.7% · Q4 6.7% · 4Q avg 10.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	88.0%	87.9% 0.1 pts better	81.7% 6.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 93.2% · Q2 85.4% · Q3 80.1% · Q4 93.8% · 4Q avg 88.0%
Percentage of short-stay residents who had an outpatient emergency department visit	15.8%	15.3% 0.5 pts worse	12.0% 3.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 15.8% · Observed 17.2% · Expected 12.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.6%	2.6% 1 pts better	1.6% About the same	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 3.0% · Q4 2.5% · 4Q avg 1.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	81.0%	84.6% 3.6 pts worse	79.7% 1.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 81.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	26.6%	27.9% 1.3 pts better	23.9% 2.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 26.6% · Observed 28.1% · Expected 25.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-30 · Fire 2025-01-30

11 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2023-09-14 · Fire 2023-09-14

5 health deficiencies

Top issue: Resident Rights (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2021-08-13 · Fire 2021-08-13

11 health deficiencies

Top issue: Resident Rights (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-01-30

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-03-10

F · Potential for more than minimal harm 2025-01-30

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2025-03-10

D · Potential for more than minimal harm 2025-01-30

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-03-10

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-27

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2026-03-02

D · Potential for more than minimal harm 2026-01-27

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2026-03-02

D · Potential for more than minimal harm 2025-09-03

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-10-07

F · Potential for more than minimal harm 2025-01-30

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2025-03-10

E · Potential for more than minimal harm 2025-01-30

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2025-03-10

E · Potential for more than minimal harm 2025-01-30

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-03-10

E · Potential for more than minimal harm 2025-01-30

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-10

D · Potential for more than minimal harm 2025-01-30

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-03-10

D · Potential for more than minimal harm 2025-01-30

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 2025-03-10

D · Potential for more than minimal harm 2025-01-30

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-03-10

D · Potential for more than minimal harm 2025-01-30

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-03-10

D · Potential for more than minimal harm 2024-05-22

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-07-01

E · Potential for more than minimal harm 2024-01-26

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-03-01

E · Potential for more than minimal harm 2024-01-26

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 2024-03-01

D · Potential for more than minimal harm 2024-01-26

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-03-01

D · Potential for more than minimal harm 2023-12-05

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-03-01

D · Potential for more than minimal harm 2023-12-05

F761 · Pharmacy Service Deficiencies

Health

Corrected 2023-11-15

E · Potential for more than minimal harm 2023-09-14

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2023-10-20

D · Potential for more than minimal harm 2023-09-14

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2023-10-20

D · Potential for more than minimal harm 2023-09-14

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-10-20

D · Potential for more than minimal harm 2023-09-14