Cycle 1
Health 2025-01-09 · Fire 2025-01-09
13 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Vicksburg, MS
The Bluffs Rehabilitation And Healthcare Center
1-star overall rating with 1-star inspections with $8,000 in total fines with 13 recent health deficiencies
2850 Porter's Chapel Road, Vicksburg, MS
(601) 638-9211
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
107
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nexion Health
Operator or chain grouping
Approved since
1991-08-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
52 facilities
Chain averages 2 overall / 2 health / 3 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
0.37
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
3.59
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.17
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.71
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,085
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
8.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.54% · Performance 23.26% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.69% · Performance 10.39% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.22
Baseline 60.91% · Performance 58.68% · Measure score 1.22 · Achievement 1.22 · Improvement 0.12
Adjusted total nurse staffing
2.18
Baseline 4.38 hours · Performance 3.70 hours · Measure score 2.18 · Achievement 2.18 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.81% |
10.72%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 69 · Observed rate 20.29% · Lower 95% interval 7.43% |
| Discharge to community | 45.36% |
50.57%
5.2 pts worse
|
No Different than the National Rate · Eligible stays 63 · Observed rate 33.33% · Lower 95% interval 34.46% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 87.27% |
95.27%
8 pts worse
|
Numerator 48 · Denominator 55 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 55 |
| Discharge self-care score | 32.14% |
53.69%
21.5 pts worse
|
Numerator 9 · Denominator 28 |
| Discharge mobility score | 21.43% |
50.94%
29.5 pts worse
|
Numerator 6 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 3.64% |
2.29%
1.4 pts worse
|
Numerator 2 · Denominator 55 · Adjusted rate 2.61% |
| Healthcare-associated infections requiring hospitalization | 10.39% |
7.12%
3.3 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 20% · Lower 95% interval 5.94% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 118 |
| Staff flu vaccination coverage | 2.46% |
42%
39.5 pts worse
|
Numerator 3 · Denominator 122 |
| Discharge function score | 32.14% |
56.45%
24.3 pts worse
|
Numerator 9 · Denominator 28 |
| Transfer of health information to provider | 97.37% |
95.95%
1.4 pts better
|
Numerator 37 · Denominator 38 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.17% |
25.2%
21 pts worse
|
Numerator 1 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.6% |
95.7%
0.1 pts worse
|
93.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.5% · Q2 93.2% · Q3 97.7% · Q4 98.8% · 4Q avg 95.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.7% |
97.0%
3.3 pts worse
|
95.5%
1.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long 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 long-stay residents who have depressive symptoms | 1.8% |
1.6%
0.2 pts worse
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 2.9% · Q3 1.4% · Q4 1.4% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 0.6% |
6.1%
5.5 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.6% |
24.4%
3.8 pts better
|
19.6%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 16.5% · Q3 21.7% · Q4 24.4% · 4Q avg 20.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.2% |
23.4%
8.2 pts better
|
16.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 19.4% · Q3 14.8% · Q4 9.6% · 4Q avg 15.2% · 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 | 17.0% |
22.8%
5.8 pts better
|
16.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q3 15.0% · Q4 28.4% · 4Q avg 17.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.2% |
20.6%
1.4 pts better
|
14.9%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 14.7% · Q3 21.4% · Q4 24.2% · 4Q avg 19.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.5% |
1.5%
2 pts worse
|
1.0%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.4% · Q3 3.9% · Q4 1.3% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
2.5%
1.1 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.7% · Q3 3.4% · Q4 0.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.4% |
21.4%
7 pts worse
|
19.8%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.1% · Q2 25.7% · Q3 17.8% · Q4 49.7% · 4Q avg 28.4% |
| Percentage of long-stay residents with pressure ulcers | 12.1% |
6.9%
5.2 pts worse
|
5.1%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 11.9% · Q3 13.5% · Q4 11.3% · 4Q avg 12.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 66.2% |
87.9%
21.7 pts worse
|
81.7%
15.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 62.5% · Q2 66.7% · Q3 77.0% · Q4 61.6% · 4Q avg 66.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.2% |
15.3%
7.9 pts worse
|
12.0%
11.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.2% · Observed 28.2% · Expected 13.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.6% |
2.6%
1 pts worse
|
1.6%
2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.1% · Q3 6.1% · Q4 5.6% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.5% |
84.6%
25.1 pts worse
|
79.7%
20.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.7% |
27.9%
4.8 pts worse
|
23.9%
8.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.7% · Observed 46.2% · Expected 33.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-26 · Fire 2023-10-26
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-06-16 · Fire 2022-06-16
6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2022-06-16
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-07-15
Inspection history
Recent health citations
G · Actual harm
2025-09-23
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-10-14
G · Actual harm
2025-09-23
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 2025-10-14
D · Potential for more than minimal harm
2025-02-25
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-02-19
F · Potential for more than minimal harm
2025-01-09
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-01-31
F · Potential for more than minimal harm
2025-01-09
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-01-31
E · Potential for more than minimal harm
2025-01-09
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 2025-01-31
E · Potential for more than minimal harm
2025-01-09
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 2025-01-31
E · Potential for more than minimal harm
2025-01-09
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 2025-01-31
E · Potential for more than minimal harm
2025-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-09
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-09
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 2025-01-31
D · Potential for more than minimal harm
2025-01-09
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 2025-01-31
D · Potential for more than minimal harm
2025-01-09
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-09
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 2025-01-31
B · Minimal harm
2025-01-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-31
G · Actual harm
2023-10-26
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 2023-11-24
G · Actual harm
2023-10-26
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-26
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 2023-11-24
D · Potential for more than minimal harm
2023-10-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-24
E · Potential for more than minimal harm
2022-06-16
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-07-22
D · Potential for more than minimal harm
2022-06-16
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 2022-07-22
D · Potential for more than minimal harm
2022-06-16
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 2022-07-22
D · Potential for more than minimal harm
2022-06-16
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 2022-07-22
D · Potential for more than minimal harm
2022-06-16
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-07-22
Penalties and ownership
What sits behind the stars
$4,000
2023-10-26
Fine
Fine · fine $4,000
Fine
$4,000
2023-10-26
Fine
Fine · fine $4,000
Fine
$0
2023-10-26
Payment Denial
Payment Denial · denial start 2023-11-22 · 2 days
2 day denial
Ownership
Nexion Health Of Ohi Inc
5% Or Greater Direct Ownership Interest · Organization
Bolt, Bretton
5% Or Greater Indirect Ownership Interest · Individual
Herdrich, William
Corporate Director · Individual
Kirley, Francis
5% Or Greater Indirect Ownership Interest · Individual
Kirley, Francis
Corporate Director · Individual
Kirley, Francis
Corporate Officer · Individual
Lee, Brian
Corporate Director · Individual
Lee, Brian
Corporate Officer · Individual
Morgan, Amanda
Operational/Managerial Control · Individual
Nexion Health Leasing, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Nexion Health, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Nexion Health, Inc.
Operational/Managerial Control · Organization
Riner, Meera
Corporate Director · Individual
Riner, Meera
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Shady Lawn Health And Rehabilitation
Vicksburg, MS
5-star overall rating with 5-star inspections with 2 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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