Cycle 1
Health 2024-09-13 · Fire 2024-09-13
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Mccomb, MS
Mccomb Community Care Center
2-star overall rating with 3-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
415 Marion Ave, Mccomb, MS
(601) 684-8700
Overall
2 / 5
CMS overall stars
Health inspections
3 / 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
140
Certified beds
Average residents
111
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Norbert Bennett & Donald Denz
Operator or chain grouping
Approved since
1989-04-01
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
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
0.16
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.41
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.47
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
4.03
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.55
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.11
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.18
CMS adjusted RN staffing hours
Adjusted total hours
4.74
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,527
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9855
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.29% · Performance 21.34% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.18
Baseline 11.44% · Performance 7.78% · Measure score 5.18 · Achievement 0 · Improvement 5.18
Total nurse turnover
1.17
Baseline 56.29% · Performance 58.90% · Measure score 1.17 · Achievement 1.17 · Improvement 0
Adjusted total nurse staffing
5.46
Baseline 4.15 hours · Performance 4.63 hours · Measure score 5.46 · Achievement 5.46 · Improvement 2.46
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.65% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 163 · Observed rate 10.43% · Lower 95% interval 8.1% |
| Discharge to community | 46.21% |
50.57%
4.4 pts worse
|
No Different than the National Rate · Eligible stays 141 · Observed rate 41.84% · Lower 95% interval 37.88% |
| Medicare spending per beneficiary | 1.31 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 99.04% |
95.27%
3.8 pts better
|
Numerator 103 · Denominator 104 |
| Falls with major injury | 0.96% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 104 |
| Discharge self-care score | 65.38% |
53.69%
11.7 pts better
|
Numerator 34 · Denominator 52 |
| Discharge mobility score | 53.85% |
50.94%
2.9 pts better
|
Numerator 28 · Denominator 52 |
| Pressure ulcers or injuries, new or worsened | 9.62% |
2.29%
7.3 pts worse
|
Numerator 10 · Denominator 104 · Adjusted rate 9.13% |
| Healthcare-associated infections requiring hospitalization | 7.78% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 80 · Observed rate 8.75% · Lower 95% interval 4.39% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 189 |
| Staff flu vaccination coverage | 28.26% |
42%
13.7 pts worse
|
Numerator 52 · Denominator 184 |
| Discharge function score | 53.85% |
56.45%
2.6 pts worse
|
Numerator 28 · Denominator 52 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 42 · Denominator 42 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 28 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 9.43% |
25.2%
15.8 pts worse
|
Numerator 5 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.4
0.1 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.7 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
2.9
0.1 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 3.2 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
95.7%
4 pts worse
|
93.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 89.9% · Q2 88.7% · Q3 97.0% · Q4 91.2% · 4Q avg 91.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
97.0%
2 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
3.2%
0.3 pts worse
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.1% · Q3 4.0% · Q4 2.9% · 4Q avg 3.5% · 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 | 7.3% |
6.1%
1.2 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 11.5% · Q3 9.0% · Q4 1.1% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.7% |
24.4%
8.3 pts worse
|
19.6%
13.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.9% · Q2 35.2% · Q3 31.1% · Q4 32.6% · 4Q avg 32.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.3% |
23.4%
1.1 pts better
|
16.7%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 25.0% · Q3 20.3% · Q4 23.6% · 4Q avg 22.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.8% |
0.2%
0.6 pts worse
|
0.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.0% · Q4 1.0% · 4Q avg 0.8% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.8% |
22.8%
4 pts worse
|
16.3%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.3% · Q2 33.2% · Q3 10.0% · Q4 22.1% · 4Q avg 26.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.6% |
20.6%
5 pts better
|
14.9%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 14.9% · Q3 14.9% · Q4 17.1% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.5%
0.5 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.7% · Q4 1.5% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
2.5%
1.7 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 1.0% · Q4 1.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.5% |
21.4%
0.9 pts better
|
19.8%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 24.4% · Q3 20.0% · Q4 23.4% · 4Q avg 20.5% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
6.9%
0.4 pts better
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 5.9% · Q3 6.6% · Q4 4.7% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.7% |
87.9%
2.8 pts better
|
81.7%
9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 91.6% · Q3 88.8% · Q4 85.5% · 4Q avg 90.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.2% |
15.3%
0.9 pts worse
|
12.0%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.2% · Observed 17.2% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
2.6%
0.9 pts better
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.6% · Q3 1.6% · Q4 1.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.9% |
84.6%
5.7 pts worse
|
79.7%
0.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.8% |
27.9%
4.9 pts worse
|
23.9%
8.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.8% · Observed 34.5% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-08 · Fire 2022-12-08
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2019-07-02 · Fire 2019-07-02
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-09-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-09-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-23
D · Potential for more than minimal harm
2022-12-08
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2022-12-12
D · Potential for more than minimal harm
2019-07-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-07-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-07
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 2025-05-09
D · Potential for more than minimal harm
2025-04-07
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 2025-05-09
D · Potential for more than minimal harm
2025-04-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-09
D · Potential for more than minimal harm
2024-09-13
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-09-13
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 2024-10-23
D · Potential for more than minimal harm
2024-09-13
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 2024-10-23
D · Potential for more than minimal harm
2024-09-13
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 2024-10-23
D · Potential for more than minimal harm
2024-09-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-23
D · Potential for more than minimal harm
2023-05-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-03
D · Potential for more than minimal harm
2022-12-08
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-08
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-01-16
F · Potential for more than minimal harm
2019-07-02
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 2019-08-26
D · Potential for more than minimal harm
2019-07-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-08-26
D · Potential for more than minimal harm
2019-07-02
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2019-08-26
D · Potential for more than minimal harm
2019-07-02
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2019-08-26
C · Minimal harm
2019-07-02
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-08-26
Penalties and ownership
What sits behind the stars
Ownership
D&N, LLC
5% Or Greater Direct Ownership Interest · Organization
Dtd Hc, LLC
5% Or Greater Direct Ownership Interest · Organization
Bennett, Norbert
5% Or Greater Indirect Ownership Interest · Individual
Denz, Donald
5% Or Greater Indirect Ownership Interest · Individual
Donald T Denz Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Norbert A Bennett Irrv Tr Fbo Children
5% Or Greater Indirect Ownership Interest · Organization
Norbert A Bennett Irrv Tr Fbo Grandchildren
5% Or Greater Indirect Ownership Interest · Organization
Smith, Rhonda
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Camellia Estates
Mccomb, MS
4-star overall rating with 4-star inspections with $7,066 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Courtyard Health And Rehabilitation
Mccomb, MS
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $148,196 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Liberty Community Living Ctr
Liberty, MS
1-star overall rating with 2-star inspections with $8,988 in total fines with 10 recent health deficiencies
Jump out