Cycle 1
Health 2024-10-09 · Fire 2024-10-09
11 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)
Columbus, MS
The Windsor Place
1-star overall rating with 2-star inspections with $50,947 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
81 Windsor Boulevard, Columbus, MS
(662) 241-5518
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
130
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1999-02-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
946
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.84
Composite VBP score used to determine payment impact.
Payment multiplier
1.0168
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.18
Baseline 24.38% · Performance 19.47% · Measure score 6.18 · Achievement 4.23 · Improvement 6.18
Healthcare-associated infections
6.26
Baseline 11.49% · Performance 7.10% · Measure score 6.26 · Achievement 2.46 · Improvement 6.26
Total nurse turnover
7.35
Baseline 39.56% · Performance 33.64% · Measure score 7.35 · Achievement 7.35 · Improvement 3.53
Adjusted total nurse staffing
4.94
Baseline 3.64 hours · Performance 4.48 hours · Measure score 4.94 · Achievement 4.94 · Improvement 3.44
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.78% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 289 · Observed rate 7.27% · Lower 95% interval 6.7% |
| Discharge to community | 56.46% |
50.57%
5.9 pts better
|
No Different than the National Rate · Eligible stays 220 · Observed rate 50% · Lower 95% interval 49.69% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.07% |
95.27%
3.8 pts better
|
Numerator 212 · Denominator 214 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 214 |
| Discharge self-care score | 62.24% |
53.69%
8.6 pts better
|
Numerator 89 · Denominator 143 |
| Discharge mobility score | 66.43% |
50.94%
15.5 pts better
|
Numerator 95 · Denominator 143 |
| Pressure ulcers or injuries, new or worsened | 4.67% |
2.29%
2.4 pts worse
|
Numerator 10 · Denominator 214 · Adjusted rate 4.6% |
| Healthcare-associated infections requiring hospitalization | 7.1% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 173 · Observed rate 6.94% · Lower 95% interval 4.52% |
| Staff COVID-19 vaccination coverage | 2.24% |
8.2%
6 pts worse
|
Numerator 6 · Denominator 268 |
| Staff flu vaccination coverage | 36.84% |
42%
5.2 pts worse
|
Numerator 77 · Denominator 209 |
| Discharge function score | 67.13% |
56.45%
10.7 pts better
|
Numerator 96 · Denominator 143 |
| Transfer of health information to provider | 98.41% |
95.95%
2.5 pts better
|
Numerator 62 · Denominator 63 |
| Transfer of health information to patient | 96.77% |
96.28%
0.5 pts better
|
Numerator 90 · Denominator 93 |
| Resident COVID-19 vaccinations up to date | 2.46% |
25.2%
22.7 pts worse
|
Numerator 3 · Denominator 122 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.4
0.2 pts better
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.3 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.6 |
2.9
0.7 pts worse
|
1.8
1.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 3.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.9% |
95.7%
2.8 pts worse
|
93.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.5% · Q3 83.2% · Q4 93.2% · 4Q avg 92.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.8% |
97.0%
1.2 pts worse
|
95.5%
0.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.2%
0.6 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 4.5% · Q3 3.5% · Q4 4.3% · 4Q avg 3.8% · 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 | 5.7% |
6.1%
0.4 pts better
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 3.3% · Q3 6.2% · Q4 4.2% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.7% |
24.4%
6.7 pts better
|
19.6%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 18.0% · Q3 19.0% · Q4 17.2% · 4Q avg 17.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.9% |
23.4%
5.5 pts worse
|
16.7%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 32.5% · Q3 23.5% · Q4 29.5% · 4Q avg 28.9% · 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% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.2% |
22.8%
1.4 pts worse
|
16.3%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.0% · Q2 25.3% · Q3 12.6% · Q4 24.0% · 4Q avg 24.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.8% |
20.6%
9.2 pts worse
|
14.9%
14.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.9% · Q2 36.0% · Q3 23.1% · Q4 25.6% · 4Q avg 29.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.2% |
1.5%
1.7 pts worse
|
1.0%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.3% · Q3 4.2% · Q4 2.3% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.9% |
2.5%
3.4 pts worse
|
1.7%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 2.9% · Q3 9.2% · Q4 5.3% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.3% |
21.4%
2.9 pts worse
|
19.8%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 28.6% · Q3 15.0% · Q4 22.9% · 4Q avg 24.3% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
6.9%
0.7 pts better
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 5.8% · Q3 5.9% · Q4 4.9% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
87.9%
9.9 pts better
|
81.7%
16.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.1% · Q2 98.0% · Q3 99.0% · Q4 99.0% · 4Q avg 97.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.4% |
15.3%
7.1 pts worse
|
12.0%
10.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 20.7% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
2.6%
1.8 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.7% |
84.6%
6.9 pts worse
|
79.7%
2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.3% |
27.9%
2.4 pts worse
|
23.9%
6.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.3% · Observed 24.9% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-27 · Fire 2023-07-27
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-10-28 · Fire 2021-10-28
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
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
2024-10-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-06
Inspection history
Recent health citations
G · Actual harm
2024-10-09
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 2024-11-06
G · Actual harm
2024-10-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-06
F · Potential for more than minimal harm
2024-10-09
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 2024-11-06
E · Potential for more than minimal harm
2024-10-09
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-10-09
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 2024-11-06
D · Potential for more than minimal harm
2024-10-09
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 2024-11-06
D · Potential for more than minimal harm
2024-10-09
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 2024-11-06
D · Potential for more than minimal harm
2024-10-09
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 2024-11-06
D · Potential for more than minimal harm
2024-10-09
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-10-09
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 2024-11-06
D · Potential for more than minimal harm
2024-10-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-05-16
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 2024-06-20
D · Potential for more than minimal harm
2023-07-27
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-09-05
D · Potential for more than minimal harm
2023-07-27
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 2023-09-05
D · Potential for more than minimal harm
2023-07-27
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 2023-09-05
D · Potential for more than minimal harm
2023-07-27
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-05
D · Potential for more than minimal harm
2023-07-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-05
D · Potential for more than minimal harm
2023-07-27
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-09-05
D · Potential for more than minimal harm
2023-07-27
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-09-05
D · Potential for more than minimal harm
2023-07-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-05
H · Actual harm
2021-10-28
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-11-18
H · Actual harm
2021-10-28
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 2021-11-18
E · Potential for more than minimal harm
2021-10-28
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 2021-11-18
D · Potential for more than minimal harm
2021-10-28
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 2021-11-18
D · Potential for more than minimal harm
2021-10-28
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2021-11-18
D · Potential for more than minimal harm
2021-10-28
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2021-11-18
Penalties and ownership
What sits behind the stars
$5,419
2024-10-09
Fine
Fine · fine $5,419
Fine
$5,420
2024-10-09
Fine
Fine · fine $5,420
Fine
$40,108
2023-07-27
Fine
Fine · fine $40,108
Fine
Ownership
Phillips, Oliver
5% Or Greater Direct Ownership Interest · Individual
Mascarenas, Sandra
5% Or Greater Direct Ownership Interest · Individual
Phillips, Gregory
5% Or Greater Direct Ownership Interest · Individual
Phillips, Helen
5% Or Greater Direct Ownership Interest · Individual
Phillips, Kenneth
5% Or Greater Direct Ownership Interest · Individual
Fulcher, Todd
Operational/Managerial Control · Individual
Phillips, Gregory
Operational/Managerial Control · Individual
Phillips, Gregory
Corporate Officer · Individual
Phillips, Helen
Corporate Officer · Individual
Phillips, Kenneth
Operational/Managerial Control · Individual
Phillips, Kenneth
Corporate Officer · Individual
Phillips, Oliver
Operational/Managerial Control · Individual
Phillips, Oliver
Corporate Officer · Individual
Windsor Place Nursing Center Inc
5% Or Greater Direct Ownership Interest · Organization
Windsor Place Nursing Center Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Aurora Health And Rehabilitation
Columbus, MS
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Trinity Healthcare Center
Columbus, MS
4-star overall rating with 3-star inspections with $10,033 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Vineyard Court Nursing Center
Columbus, MS
1-star overall rating with 1-star inspections with $78,952 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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