Cycle 1
Health 2025-03-27 · Fire 2025-03-27
14 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Winona, MS
Middleton Oaks Health And Rehabilitation
1-star overall rating with 1-star inspections with $10,868 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
627 Middleton Road, Winona, MS
(662) 283-1260
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
120
Certified beds
Average residents
93
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avardis Health
Operator or chain grouping
Approved since
1994-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 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
0.57
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
1.86
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
3.31
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
2.83
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.38
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
0.65
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
65%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,239
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.24
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
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
1.04
Baseline 9.91% · Performance 9.15% · Measure score 1.04 · Achievement 0 · Improvement 1.04
Total nurse turnover
0
Baseline 46.84% · Performance 65.93% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.93
Baseline 3.74 hours · Performance 3.91 hours · Measure score 2.93 · Achievement 2.93 · Improvement 0.34
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.43% |
10.72%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 20% · Lower 95% interval 8.47% |
| Discharge to community | 39.68% |
50.57%
10.9 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 26.19% · Lower 95% interval 29.46% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.56% |
95.27%
0.3 pts better
|
Numerator 86 · Denominator 90 |
| Falls with major injury | 2.22% |
0.77%
1.5 pts worse
|
Numerator 2 · Denominator 90 |
| Discharge self-care score | 46.67% |
53.69%
7 pts worse
|
Numerator 21 · Denominator 45 |
| Discharge mobility score | 46.67% |
50.94%
4.3 pts worse
|
Numerator 21 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 8.89% |
2.29%
6.6 pts worse
|
Numerator 8 · Denominator 90 · Adjusted rate 6.79% |
| Healthcare-associated infections requiring hospitalization | 9.15% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 34 · Observed rate 20.59% · Lower 95% interval 5.42% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 88 |
| Staff flu vaccination coverage | 49.4% |
42%
7.4 pts better
|
Numerator 82 · Denominator 166 |
| Discharge function score | 51.11% |
56.45%
5.3 pts worse
|
Numerator 23 · Denominator 45 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 38 · Denominator 38 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.4
0.5 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.1 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.9 |
2.9
1 pts worse
|
1.8
2.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.9 · Observed 4.1 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.4% |
95.7%
0.3 pts worse
|
93.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 85.0% · Q2 96.3% · Q3 100.0% · Q4 100.0% · 4Q avg 95.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
97.0%
1.9 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.2%
0.2 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 3.7% · Q3 2.4% · Q4 3.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.5% |
1.6%
3.9 pts worse
|
11.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 5.3% · Q3 4.1% · Q4 8.5% · 4Q avg 5.5% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
6.1%
1 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 10.7% · Q3 12.0% · Q4 4.0% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.7% |
24.4%
5.3 pts worse
|
19.6%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.0% · Q2 31.2% · Q3 24.4% · Q4 26.9% · 4Q avg 29.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 41.8% |
23.4%
18.4 pts worse
|
16.7%
25.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.4% · Q2 33.9% · Q3 37.7% · Q4 46.8% · 4Q avg 41.8% · 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 | 8.7% |
22.8%
14.1 pts better
|
16.3%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 4.1% · Q3 3.3% · Q4 9.1% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.1% |
20.6%
9.5 pts better
|
14.9%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 5.4% · Q3 16.2% · Q4 8.3% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.5%
0.6 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.8% · Q3 1.7% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
2.5%
0.9 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.3% · Q3 1.2% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.8% |
21.4%
4.6 pts better
|
19.8%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 33.2% · Q2 15.5% · Q3 9.4% · Q4 9.1% · 4Q avg 16.8% |
| Percentage of long-stay residents with pressure ulcers | 10.6% |
6.9%
3.7 pts worse
|
5.1%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 15.5% · Q3 6.9% · Q4 6.6% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
87.9%
6.3 pts better
|
81.7%
12.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.0% · Q2 92.6% · Q3 95.7% · Q4 100.0% · 4Q avg 94.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.1% |
15.3%
3.2 pts better
|
12.0%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 14.0% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.0% |
2.6%
2.4 pts worse
|
1.6%
3.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 10.3% · Q3 4.9% · Q4 0.0% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.5% |
84.6%
2.1 pts worse
|
79.7%
2.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.2% |
27.9%
4.3 pts worse
|
23.9%
8.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.2% · Observed 31.6% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-28 · Fire 2023-09-28
9 health deficiencies
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-10-07 · Fire 2021-10-07
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-04-24
D · Potential for more than minimal harm
2021-10-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-11-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-18
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-09-18
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 2025-10-17
G · Actual harm
2025-03-27
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 2025-04-24
G · Actual harm
2025-03-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-24
F · Potential for more than minimal harm
2025-03-27
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-04-24
F · Potential for more than minimal harm
2025-03-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-24
E · Potential for more than minimal harm
2025-03-27
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 2025-04-24
E · Potential for more than minimal harm
2025-03-27
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 2025-04-24
E · Potential for more than minimal harm
2025-03-27
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 2025-04-24
E · Potential for more than minimal harm
2025-03-27
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 2025-04-24
E · Potential for more than minimal harm
2025-03-27
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-04-24
D · Potential for more than minimal harm
2025-03-27
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-24
D · Potential for more than minimal harm
2025-03-27
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 2025-04-24
D · Potential for more than minimal harm
2025-03-27
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 2025-04-24
D · Potential for more than minimal harm
2023-10-18
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-22
E · Potential for more than minimal harm
2023-09-28
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 2023-11-03
D · Potential for more than minimal harm
2023-09-28
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 2023-11-03
D · Potential for more than minimal harm
2023-09-28
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-09-28
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-09-28
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 2023-11-03
D · Potential for more than minimal harm
2023-09-28
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 2023-11-03
D · Potential for more than minimal harm
2023-09-28
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 2023-11-03
D · Potential for more than minimal harm
2023-09-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-03
C · Minimal harm
2023-09-28
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-07-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
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 2023-08-20
D · Potential for more than minimal harm
2023-07-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-06-15
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-08-20
F · Potential for more than minimal harm
2021-10-07
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 2021-11-15
Penalties and ownership
What sits behind the stars
$5,434
2025-03-27
Fine
Fine · fine $5,434
Fine
$5,434
2025-03-27
Fine
Fine · fine $5,434
Fine
Ownership
Winona Parentco LLC
5% Or Greater Direct Ownership Interest · Organization
Art And Soul Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Fc Encore Winona LLC
5% Or Greater Security Interest · Organization
Hoback, Tiffany
Operational/Managerial Control · Individual
Jones, Tequilla
Operational/Managerial Control · Individual
Matthews, Jonathan
Operational/Managerial Control · Individual
Msop Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Nu C Ii Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Nu C Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Peeples, Mercedes
Operational/Managerial Control · Individual
Rushing, Steven
Operational/Managerial Control · Individual
Snf Care Centers LLC
5% Or Greater Indirect Ownership Interest · Organization
Snf Mgr LLC
Operational/Managerial Control · Organization
Thomas, John
Operational/Managerial Control · Individual
Zenith Holdco Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Zenith Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Vaiden Community Living Center
Vaiden, MS
3-star overall rating with 3-star inspections with 6 recent health deficiencies
#2
Grenada Living Center
Grenada, MS
3-star overall rating with 4-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Grenada Rehabilitation And Healthcare Center
Grenada, MS
1-star overall rating with 1-star inspections with abuse icon flag with $14,800 in total fines with 8 recent health deficiencies
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