Cycle 1
Health 2024-05-02 · Fire 2024-05-02
2 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Vicksburg, MS
Shady Lawn Health And Rehabilitation
5-star overall rating with 5-star inspections with 2 recent health deficiencies
60 Shady Lawn Place, Vicksburg, MS
(601) 636-1448
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Vanguard Healthcare
Operator or chain grouping
Approved since
1996-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 4 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
0.76
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.44
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
4.09
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.65
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
0.52
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.91
CMS adjusted RN staffing hours
Adjusted total hours
4.93
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,652
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55
Composite VBP score used to determine payment impact.
Payment multiplier
1.0100
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.20
Performance 19.49% · Measure score 4.20 · Achievement 4.20 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.32
Baseline 8.44% · Performance 6.78% · Measure score 4.32 · Achievement 3.53 · Improvement 4.32
Total nurse turnover
8.85
Baseline 23.08% · Performance 27.50% · Measure score 8.85 · Achievement 8.85 · Improvement 0
Adjusted total nurse staffing
4.63
Baseline 3.68 hours · Performance 4.39 hours · Measure score 4.63 · Achievement 4.63 · Improvement 2.89
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.75% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 65 · Observed rate 10.77% · Lower 95% interval 7.68% |
| Discharge to community | 52.98% |
50.57%
2.4 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 50.94% · Lower 95% interval 43.53% |
| 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 44 · Denominator 44 |
| Falls with major injury | 2.27% |
0.77%
1.5 pts worse
|
Numerator 1 · Denominator 44 |
| Discharge self-care score | 60.71% |
53.69%
7 pts better
|
Numerator 17 · Denominator 28 |
| Discharge mobility score | 60.71% |
50.94%
9.8 pts better
|
Numerator 17 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 44 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.78% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 40 · Observed rate 5% · Lower 95% interval 3.4% |
| Staff COVID-19 vaccination coverage | 4.2% |
8.2%
4 pts worse
|
Numerator 5 · Denominator 119 |
| Staff flu vaccination coverage | 52.07% |
42%
10.1 pts better
|
Numerator 63 · Denominator 121 |
| Discharge function score | 64.29% |
56.45%
7.8 pts better
|
Numerator 18 · Denominator 28 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 33 · Denominator 33 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 7 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.4
0.1 pts better
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.2 · Expected 1.8 · 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 1.0 · Expected 1.5 · 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 | 1.1% |
3.2%
2.1 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 1.1% · 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 | 0.4% |
6.1%
5.7 pts better
|
5.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.7% |
24.4%
8.7 pts better
|
19.6%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 15.9% · Q3 16.7% · Q4 13.3% · 4Q avg 15.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.0% |
23.4%
8.4 pts better
|
16.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 15.1% · Q3 13.2% · Q4 10.7% · 4Q avg 15.0% · 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 | 14.9% |
22.8%
7.9 pts better
|
16.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.6% · Q2 20.3% · Q3 8.4% · Q4 13.6% · 4Q avg 14.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.8% |
20.6%
6.8 pts better
|
14.9%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 27.1% · Q3 7.3% · Q4 8.8% · 4Q avg 13.8% · 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 0.0% · Q3 1.3% · Q4 1.1% · 4Q avg 0.9% · 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 1.6% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.9% |
21.4%
12.5 pts better
|
19.8%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 13.7% · Q3 8.4% · Q4 7.0% · 4Q avg 8.9% |
| Percentage of long-stay residents with pressure ulcers | 7.2% |
6.9%
0.3 pts worse
|
5.1%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 6.3% · Q3 5.9% · Q4 7.7% · 4Q avg 7.2% · 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 | 10.9% |
15.3%
4.4 pts better
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 10.9% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
2.6%
2 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.5% |
84.6%
13.9 pts better
|
79.7%
18.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| 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 30.9% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-19 · Fire 2023-01-19
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-09-12 · Fire 2019-09-12
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2019-09-12
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2019-10-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-05-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-05-02
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 2024-06-12
D · Potential for more than minimal harm
2024-05-02
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 2024-06-12
D · Potential for more than minimal harm
2019-09-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-10-18
Penalties and ownership
What sits behind the stars
Ownership
Vanguard Healthcare, LLC
5% Or Greater Direct Ownership Interest · Organization
Ervin General Partnership
5% Or Greater Indirect Ownership Interest · Organization
Ervin, William
5% Or Greater Indirect Ownership Interest · Individual
Fick, John
Corporate Officer · Individual
Frazier, Kenneth
W-2 Managing Employee · Individual
Jere Suzanne Ervin Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Orand LP
5% Or Greater Indirect Ownership Interest · Organization
Orand, William
5% Or Greater Indirect Ownership Interest · Individual
Orand, William
Corporate Director · Individual
Orand, William
Corporate Officer · Individual
Pucket, Annie
W-2 Managing Employee · Individual
Smothers, Jere
5% Or Greater Indirect Ownership Interest · Individual
West Mississippi Management Associates, LLC
Operational/Managerial Control · Organization
William Jeffrey Ervin Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
The Bluffs Rehabilitation And Healthcare Center
Vicksburg, MS
1-star overall rating with 1-star inspections with $8,000 in total fines with 13 recent health deficiencies
#2
Heritage House Nursing Center
Vicksburg, MS
4-star overall rating with 3-star inspections with 8 recent health deficiencies
#3
Vicksburg Convalescent Center
Vicksburg, MS
5-star overall rating with 5-star inspections with 1 recent health deficiencies
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