Cycle 1
Health 2025-11-18 · Fire 2025-11-18
5 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Leakesville, MS
Leakesville Rehabilitation And Nursing Center, Inc
3-star overall rating with 4-star inspections with 5 recent health deficiencies
1300 Melody Lane, Leakesville, MS
(601) 394-2331
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-09-01
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
0.58
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.32
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
3.05
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
4.95
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.90
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.99
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
4.82
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,729
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9852
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 24.64% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 10.55% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
5.68
Baseline 67.11% · Performance 40.98% · Measure score 5.68 · Achievement 5.55 · Improvement 5.68
Adjusted total nurse staffing
5.89
Baseline 4.75 hours · Performance 4.75 hours · Measure score 5.89 · Achievement 5.89 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.96% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 22.86% · Lower 95% interval 7.8% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.53 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 85.42% |
95.27%
9.8 pts worse
|
Numerator 41 · Denominator 48 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 48 |
| Discharge self-care score | 44% |
53.69%
9.7 pts worse
|
Numerator 11 · Denominator 25 |
| Discharge mobility score | 16% |
50.94%
34.9 pts worse
|
Numerator 4 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 2.08% |
2.29%
0.2 pts better
|
Numerator 1 · Denominator 48 · Adjusted rate 1.6% |
| Healthcare-associated infections requiring hospitalization | 10.55% |
7.12%
3.4 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 25% · Lower 95% interval 6.24% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 83 |
| Staff flu vaccination coverage | 12.5% |
42%
29.5 pts worse
|
Numerator 11 · Denominator 88 |
| Discharge function score | 24% |
56.45%
32.5 pts worse
|
Numerator 6 · Denominator 25 |
| Transfer of health information to provider | 95.45% |
95.95%
0.5 pts worse
|
Numerator 21 · Denominator 22 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · 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 | 3.4 |
2.4
1 pts worse
|
1.9
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 4.8 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.7 |
2.9
2.8 pts worse
|
1.8
3.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.7 · Observed 7.9 · Expected 2.3 · 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 | 1.9% |
3.2%
1.3 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.9% · Q3 1.9% · Q4 1.9% · 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 | 9.5% |
6.1%
3.4 pts worse
|
5.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 19.6% · Q3 10.2% · Q4 2.0% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.3% |
24.4%
9.9 pts worse
|
19.6%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.0% · Q2 39.6% · Q3 30.8% · Q4 32.7% · 4Q avg 34.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.2% |
23.4%
7.8 pts worse
|
16.7%
14.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.6% · Q2 35.9% · Q3 25.0% · Q4 26.3% · 4Q avg 31.2% · 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 | 24.3% |
22.8%
1.5 pts worse
|
16.3%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.9% |
20.6%
4.3 pts worse
|
14.9%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 23.9% · Q3 25.6% · Q4 25.0% · 4Q avg 24.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.5% |
1.5%
3 pts worse
|
1.0%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 4.7% · Q3 4.5% · Q4 0.0% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 8.5% |
2.5%
6 pts worse
|
1.7%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 3.9% · Q3 14.0% · Q4 6.1% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.8% |
21.4%
2.6 pts better
|
19.8%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 21.9% · Q3 11.6% · Q4 17.9% · 4Q avg 18.8% |
| Percentage of long-stay residents with pressure ulcers | 11.6% |
6.9%
4.7 pts worse
|
5.1%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 16.9% · Q3 10.7% · Q4 7.4% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.9% |
87.9%
5 pts better
|
81.7%
11.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 84.8% · Q2 94.7% · Q3 96.6% · Q4 100.0% · 4Q avg 92.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.8% |
15.3%
9.5 pts worse
|
12.0%
12.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 34.1% · Expected 15.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 9.1% |
2.6%
6.5 pts worse
|
1.6%
7.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 12.1% · Q3 8.3% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.3% |
84.6%
7.7 pts better
|
79.7%
12.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.4% |
27.9%
7.5 pts worse
|
23.9%
11.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.4% · Observed 50.0% · Expected 33.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-09 · Fire 2024-05-09
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-11-09 · Fire 2022-11-09
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
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
2024-05-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-11-25
D · Potential for more than minimal harm
2025-11-18
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-11-25
D · Potential for more than minimal harm
2025-11-18
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 2025-11-25
D · Potential for more than minimal harm
2025-11-18
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 2025-11-25
D · Potential for more than minimal harm
2025-11-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-25
D · Potential for more than minimal harm
2024-07-02
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-05-09
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-05-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-05-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-05-09
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-05-09
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-05-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-18
D · Potential for more than minimal harm
2022-11-09
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-12-02
Penalties and ownership
What sits behind the stars
Ownership
Evan Trace Cain Gst Trust
5% Or Greater Direct Ownership Interest · Organization
Logan Patrick Cain Gst Trust
5% Or Greater Direct Ownership Interest · Organization
Baughman, April
Operational/Managerial Control · Individual
Cain, Harold
Corporate Director · Individual
Cain, Harold
Corporate Officer · Individual
Corporate Management, Inc.
Operational/Managerial Control · Organization
Sullivan, Heather
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Greene County Health And Rehabilitation
Leakesville, MS
3-star overall rating with 2-star inspections with 6 recent health deficiencies
#2
George Regional Health & Rehab Center
Lucedale, MS
4-star overall rating with 4-star inspections with 5 recent health deficiencies
#3
Glen Oaks Nursing Center
Lucedale, MS
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
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