Cycle 1
Health 2025-01-16 · Fire 2025-01-16
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Madison, MS
The Madison Health And Rehab
3-star overall rating with 3-star inspections with 8 recent health deficiencies
111 Kelly Blvd, Madison, MS
(601) 355-0763
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trend Consultants
Operator or chain grouping
Approved since
2001-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 3 overall / 3 health / 4 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.71
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.39
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
3.02
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
5.13
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
2.10
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.84
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
0.23
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.84
CMS adjusted RN staffing hours
Adjusted total hours
6.04
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
468
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
69.29
Composite VBP score used to determine payment impact.
Payment multiplier
1.0220
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 19.55% · Performance 16.68% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
6.09
Baseline 9.73% · Performance 6.61% · Measure score 6.09 · Achievement 4.09 · Improvement 6.09
Total nurse turnover
1.63
Baseline 61.19% · Performance 57.03% · Measure score 1.63 · Achievement 1.63 · Improvement 0.65
Adjusted total nurse staffing
10
Baseline 4.84 hours · Performance 6.41 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.42% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 329 · Observed rate 7.6% · Lower 95% interval 7.64% |
| Discharge to community | 58.8% |
50.57%
8.2 pts better
|
Better than the National Rate · Eligible stays 357 · Observed rate 57.7% · Lower 95% interval 53.72% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 62.7% |
95.27%
32.6 pts worse
|
Numerator 158 · Denominator 252 |
| Falls with major injury | 0.79% |
0.77%
About the same
|
Numerator 2 · Denominator 252 |
| Discharge self-care score | 74.38% |
53.69%
20.7 pts better
|
Numerator 151 · Denominator 203 |
| Discharge mobility score | 73.4% |
50.94%
22.5 pts better
|
Numerator 149 · Denominator 203 |
| Pressure ulcers or injuries, new or worsened | 1.59% |
2.29%
0.7 pts better
|
Numerator 4 · Denominator 252 · Adjusted rate 1.74% |
| Healthcare-associated infections requiring hospitalization | 6.61% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 242 · Observed rate 4.96% · Lower 95% interval 3.99% |
| Staff COVID-19 vaccination coverage | 0.95% |
8.2%
7.2 pts worse
|
Numerator 1 · Denominator 105 |
| Staff flu vaccination coverage | 72.36% |
42%
30.4 pts better
|
Numerator 144 · Denominator 199 |
| Discharge function score | 76.85% |
56.45%
20.4 pts better
|
Numerator 156 · Denominator 203 |
| Transfer of health information to provider | 96.61% |
95.95%
0.7 pts better
|
Numerator 57 · Denominator 59 |
| Transfer of health information to patient | 97.19% |
96.28%
0.9 pts better
|
Numerator 173 · Denominator 178 |
| Resident COVID-19 vaccinations up to date | 6.12% |
25.2%
19.1 pts worse
|
Numerator 9 · Denominator 147 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.4
About the same
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.6 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.9
1.1 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.8 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.3% |
95.7%
2.4 pts worse
|
93.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 90.5% · Q3 90.9% · 4Q avg 93.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.9% |
97.0%
4.1 pts worse
|
95.5%
2.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
| 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 3.4% · Q2 0.0% · Q3 0.0% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
6.1%
1.3 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 10.0% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.4% |
24.4%
3 pts worse
|
19.6%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 28.6% · Q3 25.0% · 4Q avg 27.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 34.9% |
23.4%
11.5 pts worse
|
16.7%
18.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 34.9% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.0% |
22.8%
8.8 pts better
|
16.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.3% |
20.6%
12.3 pts better
|
14.9%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.5%
0.7 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.2% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.5% |
2.5%
2 pts worse
|
1.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.8% · Q3 4.5% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.0% |
21.4%
8.6 pts worse
|
19.8%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 29.9% · 4Q avg 30.0% |
| 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 4.1% · Q2 0.0% · Q3 6.4% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.6% |
87.9%
6.7 pts better
|
81.7%
12.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 93.5% · Q3 91.7% · Q4 97.1% · 4Q avg 94.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.3% |
15.3%
4 pts better
|
12.0%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.3% · Observed 9.6% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
2.6%
1.5 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.8% · Q4 1.6% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.2% |
84.6%
6.4 pts worse
|
79.7%
1.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.1% |
27.9%
9.8 pts better
|
23.9%
5.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.1% · Observed 13.6% · Expected 18.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-21 · Fire 2023-09-21
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 2022-04-07 · Fire 2022-04-07
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-04-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-04-08
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-16
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 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
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 2025-02-14
D · Potential for more than minimal harm
2025-01-16
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 2025-02-14
D · Potential for more than minimal harm
2025-01-16
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 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-14
E · Potential for more than minimal harm
2023-09-21
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 2023-10-31
F · Potential for more than minimal harm
2022-04-07
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 2022-05-31
F · Potential for more than minimal harm
2022-04-07
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-05-31
F · Potential for more than minimal harm
2022-04-07
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-05-31
E · Potential for more than minimal harm
2022-04-07
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-05-31
D · Potential for more than minimal harm
2022-04-07
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 2022-05-31
D · Potential for more than minimal harm
2022-04-07
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-05-31
D · Potential for more than minimal harm
2022-04-07
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2022-05-31
D · Potential for more than minimal harm
2022-04-07
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 2022-05-31
D · Potential for more than minimal harm
2022-04-07
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 2022-05-31
D · Potential for more than minimal harm
2022-04-07
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 2022-05-31
D · Potential for more than minimal harm
2022-04-07
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 2022-05-31
D · Potential for more than minimal harm
2022-04-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-31
Penalties and ownership
What sits behind the stars
Ownership
Kelly, Charles
5% Or Greater Direct Ownership Interest · Individual
Kelly, Charles
Operational/Managerial Control · Individual
Kelly, Rita
Corporate Director · Individual
Trend Consultants LLC
Operational/Managerial Control · Organization
Warnock, Lori
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
The Nichols Center
Madison, MS
2-star overall rating with 2-star inspections with $7,901 in total fines with 5 recent health deficiencies
#2
Highland Home
Ridgeland, MS
2-star overall rating with 2-star inspections with $10,033 in total fines with 7 recent health deficiencies
#3
Pine Forest Health And Rehabilitation
Jackson, MS
1-star overall rating with 1-star inspections with abuse icon flag with $143,764 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out