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
Staffing
Hours and turnover
RN hours / resident day
0.71
Registered nurse staffing
LPN hours / resident day
1.39
Licensed practical nurse staffing
Aide hours / resident day
3.02
Nurse aide staffing
Weekend hours
3.84
Weekend nurse staffing
RN turnover
58%
Annual RN turnover
Total nurse turnover
56%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
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