Cycle 1
Health 2025-04-02 · Fire 2025-04-02
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Houston, MS
Trend Health And Rehab Of Houston
2-star overall rating with 2-star inspections with $12,155 in total fines with 8 recent health deficiencies
1000 East Madison Street, Houston, MS
(662) 456-1101
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
66
Certified beds
Average residents
48
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trend Consultants
Operator or chain grouping
Approved since
2004-07-01
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
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.91
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
4.11
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.82
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.05
CMS adjusted RN staffing hours
Adjusted total hours
4.73
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.37% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 65 · Observed rate 12.31% · Lower 95% interval 7.62% |
| Discharge to community | 52.23% |
50.57%
1.7 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 48.72% · Lower 95% interval 41.36% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.96% |
95.27%
2.7 pts better
|
Numerator 48 · Denominator 49 |
| Falls with major injury | 4.08% |
0.77%
3.3 pts worse
|
Numerator 2 · Denominator 49 |
| Discharge self-care score | 65.22% |
53.69%
11.5 pts better
|
Numerator 15 · Denominator 23 |
| Discharge mobility score | 73.91% |
50.94%
23 pts better
|
Numerator 17 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 49 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 100 |
| Staff flu vaccination coverage | 95.19% |
42%
53.2 pts better
|
Numerator 99 · Denominator 104 |
| Discharge function score | 73.91% |
56.45%
17.5 pts better
|
Numerator 17 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 22 |
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 1.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.5 |
2.9
2.6 pts worse
|
1.8
3.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.5 · Observed 4.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
95.7%
2 pts better
|
93.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 90.9% · Q3 100.0% · Q4 100.0% · 4Q avg 97.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
97.0%
1 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.6% |
3.2%
1.4 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 4.5% · Q3 4.8% · Q4 2.3% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
1.6%
0.9 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 5.5% |
6.1%
0.6 pts better
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 2.8% · Q3 2.9% · Q4 5.1% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.4% |
24.4%
6 pts better
|
19.6%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 16.2% · Q3 16.2% · Q4 23.1% · 4Q avg 18.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.4% |
23.4%
3 pts worse
|
16.7%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 26.1% · Q3 25.0% · Q4 23.3% · 4Q avg 26.4% · 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 | 32.7% |
22.8%
9.9 pts worse
|
16.3%
16.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 35.8% · Q4 26.5% · 4Q avg 32.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.3% |
20.6%
10.7 pts worse
|
14.9%
16.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 34.4% · Q3 25.0% · Q4 34.3% · 4Q avg 31.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
1.5%
0.7 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.0% · Q3 0.0% · Q4 4.6% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
2.5%
0.1 pts better
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.3% · Q3 2.6% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.5% |
21.4%
0.9 pts better
|
19.8%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 28.0% · Q3 28.3% · Q4 16.1% · 4Q avg 20.5% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
6.9%
3.3 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 6.9% · Q4 5.2% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.0% |
87.9%
4.1 pts better
|
81.7%
10.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.5% · Q2 95.2% · Q4 92.9% · 4Q avg 92.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.0% |
15.3%
9.7 pts worse
|
12.0%
13 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 25.6% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.1% |
2.6%
1.5 pts worse
|
1.6%
2.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.8% |
84.6%
2.8 pts worse
|
79.7%
2.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.3% |
27.9%
1.6 pts better
|
23.9%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 23.1% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-21 · Fire 2024-03-21
15 health deficiencies
Top issue: Resident Rights (5 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-12-14 · Fire 2022-12-14
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 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
2024-03-21
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-04-22
F · Potential for more than minimal harm
2024-03-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-22
F · Potential for more than minimal harm
2022-12-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-21
D · Potential for more than minimal harm
2022-12-14
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-01-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-02
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 2025-05-15
E · Potential for more than minimal harm
2025-04-02
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 2025-05-15
E · Potential for more than minimal harm
2025-04-02
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-02
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 2025-05-15
D · Potential for more than minimal harm
2025-04-02
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 2025-05-15
C · Minimal harm
2025-04-02
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2025-05-15
D · Potential for more than minimal harm
2024-03-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-21
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 2024-04-30
D · Potential for more than minimal harm
2024-03-21
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 2024-04-30
D · Potential for more than minimal harm
2024-03-21
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-21
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-21
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 2024-04-30
D · Potential for more than minimal harm
2024-03-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-21
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 2024-04-30
D · Potential for more than minimal harm
2024-03-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-21
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 2024-04-30
D · Potential for more than minimal harm
2024-03-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-21
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 2024-04-30
D · Potential for more than minimal harm
2024-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-30
B · Minimal harm
2024-03-21
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-04-30
G · Actual harm
2023-05-16
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 2023-06-29
G · Actual harm
2023-05-16
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 2023-06-29
G · Actual harm
2023-05-16
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-06-29
D · Potential for more than minimal harm
2022-12-14
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 2023-01-21
D · Potential for more than minimal harm
2022-12-14
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 2023-01-21
D · Potential for more than minimal harm
2022-12-14
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 2023-01-21
D · Potential for more than minimal harm
2022-12-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-21
Penalties and ownership
What sits behind the stars
$12,155
2023-05-16
Fine
Fine · fine $12,155
Fine
$0
2023-05-16
Payment Denial
Payment Denial · denial start 2023-06-17 · 12 days
12 day denial
Ownership
Kelly, Charles
5% Or Greater Direct Ownership Interest · Individual
Kelly, Charles
General Partnership Interest · Individual
Kelly, Charles
Operational/Managerial Control · Individual
Kelly, Charles
5% Or Greater Mortgage Interest · Individual
Kelly, Rita
5% Or Greater Direct Ownership Interest · Individual
Kelly, Rita
Limited Partnership Interest · Individual
Kelly, Rita
5% Or Greater Mortgage Interest · Individual
Lott, Sandra
Operational/Managerial Control · Individual
Trend Consultants LLC
Operational/Managerial Control · Organization
Warnock, Lori
Operational/Managerial Control · Individual
Warnock, Lori
Corporate Director · Individual
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#3
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