Cycle 1
Health 2025-12-03 · Fire 2025-12-03
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Pontotoc, MS
Pontotoc Health & Rehab Center
5-star overall rating with 5-star inspections with 3 recent health deficiencies
278 West Eighth Street, Pontotoc, MS
(662) 489-6411
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
48
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Advanced Health Care Management
Operator or chain grouping
Approved since
2001-01-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 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
0.58
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.43
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
4.35
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
2.01
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.44
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
4.83
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,398
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.97
Composite VBP score used to determine payment impact.
Payment multiplier
1.0040
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.90
Baseline 21.50% · Performance 20.09% · Measure score 2.90 · Achievement 2.90 · Improvement 2.66
Healthcare-associated infections
4.66
Baseline 9.47% · Performance 7.16% · Measure score 4.66 · Achievement 2.25 · Improvement 4.66
Total nurse turnover
7.28
Baseline 35.71% · Performance 33.93% · Measure score 7.28 · Achievement 7.28 · Improvement 1.14
Adjusted total nurse staffing
5.15
Baseline 3.99 hours · Performance 4.54 hours · Measure score 5.15 · Achievement 5.15 · Improvement 2.59
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.05% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 146 · Observed rate 10.96% · Lower 95% interval 8.18% |
| Discharge to community | 59.33% |
50.57%
8.8 pts better
|
No Different than the National Rate · Eligible stays 104 · Observed rate 57.69% · Lower 95% interval 50.21% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 104 · Denominator 104 |
| Falls with major injury | 0.96% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 104 |
| Discharge self-care score | 56% |
53.69%
2.3 pts better
|
Numerator 42 · Denominator 75 |
| Discharge mobility score | 62.67% |
50.94%
11.7 pts better
|
Numerator 47 · Denominator 75 |
| Pressure ulcers or injuries, new or worsened | 1.92% |
2.29%
0.4 pts better
|
Numerator 2 · Denominator 104 · Adjusted rate 1.64% |
| Healthcare-associated infections requiring hospitalization | 7.16% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 94 · Observed rate 6.38% · Lower 95% interval 4.31% |
| Staff COVID-19 vaccination coverage | 2.67% |
8.2%
5.5 pts worse
|
Numerator 2 · Denominator 75 |
| Staff flu vaccination coverage | 9.62% |
42%
32.4 pts worse
|
Numerator 10 · Denominator 104 |
| Discharge function score | 61.33% |
56.45%
4.9 pts better
|
Numerator 46 · Denominator 75 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 47 · Denominator 47 |
| Transfer of health information to patient | 96.15% |
96.28%
0.1 pts worse
|
Numerator 25 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 37.04% |
25.2%
11.8 pts better
|
Numerator 20 · Denominator 54 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.2 |
2.4
0.8 pts worse
|
1.9
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.6 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.4 |
2.9
0.5 pts worse
|
1.8
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.6 · Expected 1.8 · 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 | 1.8% |
3.2%
1.4 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 2.3% · Q4 2.6% · 4Q avg 1.8% · 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 | 0.9% |
6.1%
5.2 pts better
|
5.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.6% |
24.4%
1.8 pts better
|
19.6%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 25.0% · Q3 20.7% · Q4 21.4% · 4Q avg 22.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.1% |
23.4%
16.3 pts better
|
16.7%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 4.2% · Q3 4.5% · Q4 8.0% · 4Q avg 7.1% · 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 | 16.9% |
22.8%
5.9 pts better
|
16.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.9% |
20.6%
4.7 pts better
|
14.9%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 22.2% · Q3 20.0% · Q4 4.0% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
1.5%
0.9 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.4% · Q3 2.2% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
2.5%
1.8 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.7% |
21.4%
4.7 pts better
|
19.8%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 17.3% · Q3 17.6% · Q4 19.2% · 4Q avg 16.7% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
6.9%
4 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.4% · Q3 3.0% · Q4 2.9% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
87.9%
12.1 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.3% |
15.3%
12 pts better
|
12.0%
8.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.3% · Observed 3.3% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.6%
2.6 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
84.6%
15.4 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.8% |
27.9%
4.1 pts better
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 22.8% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-25 · Fire 2024-07-25
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-06-08 · Fire 2023-06-08
1 health deficiencies
Top issue: Infection Control (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
2024-07-25
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-09-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-03
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 2026-01-06
D · Potential for more than minimal harm
2025-12-03
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 2026-01-06
D · Potential for more than minimal harm
2025-12-03
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 2026-01-06
D · Potential for more than minimal harm
2024-07-25
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 2024-08-23
D · Potential for more than minimal harm
2024-07-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-25
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 2024-08-23
D · Potential for more than minimal harm
2024-07-25
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-08-23
D · Potential for more than minimal harm
2023-06-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-10
Penalties and ownership
What sits behind the stars
Ownership
Advanced Healthcare Management, Inc
5% Or Greater Direct Ownership Interest · Organization
Griffin, Troy
5% Or Greater Indirect Ownership Interest · Individual
Hubbard, Gene
5% Or Greater Indirect Ownership Interest · Individual
Griffin, Troy
Corporate Officer · Individual
Griffin, Troy
W-2 Managing Employee · Individual
Hubbard, Gene
Corporate Officer · Individual
Hubbard, Gene
W-2 Managing Employee · Individual
Stephens, Donna
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Pontotoc Nursing Home
Pontotoc, MS
4-star overall rating with 3-star inspections with 4 recent health deficiencies
#2
Sunshine Health Care, Inc
Pontotoc, MS
5-star overall rating with 5-star inspections with 1 recent health deficiencies
#3
Cedars Health Center
Tupelo, MS
3-star overall rating with 2-star inspections with abuse icon flag with 6 recent health deficiencies
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