Cycle 1
Health 2024-05-30 · Fire 2024-05-30
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Columbus, MS
Trinity Healthcare Center
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
230 Airline Road, Columbus, MS
(662) 327-9404
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
56
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-12-14
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
0.85
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
3.27
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
5.02
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
4.25
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.98
CMS adjusted RN staffing hours
Adjusted total hours
5.76
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
834
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63.14
Composite VBP score used to determine payment impact.
Payment multiplier
1.0179
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.80
Baseline 18.43% · Performance 20.13% · Measure score 2.80 · Achievement 2.80 · Improvement 0
Healthcare-associated infections
4.05
Baseline 5.32% · Performance 6.62% · Measure score 4.05 · Achievement 4.05 · Improvement 0
Total nurse turnover
8.40
Baseline 41.25% · Performance 29.33% · Measure score 8.40 · Achievement 8.40 · Improvement 6.77
Adjusted total nurse staffing
10
Baseline 5.28 hours · Performance 5.97 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.28% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 213 · Observed rate 6.57% · Lower 95% interval 6.57% |
| Discharge to community | 65.66% |
50.57%
15.1 pts better
|
Better than the National Rate · Eligible stays 190 · Observed rate 64.74% · Lower 95% interval 57.38% |
| Medicare spending per beneficiary | 0.78 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.03% |
95.27%
3.8 pts better
|
Numerator 102 · Denominator 103 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 103 |
| Discharge self-care score | 40.24% |
53.69%
13.4 pts worse
|
Numerator 33 · Denominator 82 |
| Discharge mobility score | 58.54% |
50.94%
7.6 pts better
|
Numerator 48 · Denominator 82 |
| Pressure ulcers or injuries, new or worsened | 4.85% |
2.29%
2.6 pts worse
|
Numerator 5 · Denominator 103 · Adjusted rate 5.8% |
| Healthcare-associated infections requiring hospitalization | 6.62% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 125 · Observed rate 4.8% · Lower 95% interval 3.49% |
| Staff COVID-19 vaccination coverage | 0.86% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 116 |
| Staff flu vaccination coverage | 26.05% |
42%
15.9 pts worse
|
Numerator 31 · Denominator 119 |
| Discharge function score | 62.2% |
56.45%
5.8 pts better
|
Numerator 51 · Denominator 82 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 47 · Denominator 47 |
| Resident COVID-19 vaccinations up to date | 18% |
25.2%
7.2 pts worse
|
Numerator 9 · Denominator 50 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.4
0.1 pts better
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
2.9
0.5 pts better
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.4% |
97.0%
0.6 pts worse
|
95.5%
0.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.4% |
3.2%
1.2 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 3.7% · Q3 4.0% · Q4 4.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
1.6%
0.5 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 8.8% |
6.1%
2.7 pts worse
|
5.4%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 6.8% · Q3 9.5% · Q4 9.5% · 4Q avg 8.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.5% |
24.4%
2.1 pts worse
|
19.6%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 23.4% · Q3 24.4% · Q4 28.9% · 4Q avg 26.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.3% |
23.4%
15.1 pts better
|
16.7%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 9.7% · Q3 8.1% · Q4 2.6% · 4Q avg 8.3% · 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 | 32.5% |
22.8%
9.7 pts worse
|
16.3%
16.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 37.2% · 4Q avg 32.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.7% |
20.6%
6.1 pts worse
|
14.9%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.5% · Q2 27.3% · Q3 16.3% · Q4 34.1% · 4Q avg 26.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.5%
0.6 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
2.5%
2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.0% |
21.4%
7.6 pts worse
|
19.8%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 32.9% · Q3 26.5% · Q4 28.6% · 4Q avg 29.0% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
6.9%
0.6 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 10.8% · Q3 12.0% · Q4 4.5% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
87.9%
11 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.8% · Q4 98.0% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.5% |
15.3%
1.8 pts better
|
12.0%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.5% · Observed 11.8% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.6%
2.6 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.5% |
84.6%
6.9 pts better
|
79.7%
11.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.3% |
27.9%
6.6 pts better
|
23.9%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.3% · Observed 16.7% · Expected 18.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-09 · Fire 2023-03-09
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2020-02-20 · Fire 2020-02-20
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-05-30
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-06-19
F · Potential for more than minimal harm
2023-03-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-08
D · Potential for more than minimal harm
2020-02-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-04-15
Inspection history
Recent health citations
G · Actual harm
2024-05-30
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 2024-06-19
G · Actual harm
2024-05-30
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-30
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-05-30
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 2024-06-19
D · Potential for more than minimal harm
2024-05-30
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 2024-06-19
D · Potential for more than minimal harm
2024-05-30
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 2024-06-19
D · Potential for more than minimal harm
2024-05-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-19
D · Potential for more than minimal harm
2023-03-09
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-04-19
E · Potential for more than minimal harm
2020-02-20
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 2020-04-25
D · Potential for more than minimal harm
2020-02-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-04-25
Penalties and ownership
What sits behind the stars
$10,033
2024-05-30
Fine
Fine · fine $10,033
Fine
Ownership
United Methodist Senior Services Of Golden Triangle Area, Inc.
5% Or Greater Direct Ownership Interest · Organization
Tuggle, Shelley
Operational/Managerial Control · Individual
Tuggle, Shelley
Corporate Director · Individual
United Methodist Senior Services Of Golden Triangle Area, Inc.
Operational/Managerial Control · Organization
Vance, Christie
Operational/Managerial Control · Individual
Vance, Christie
Corporate Officer · Individual
Whitmire, Rachel
Operational/Managerial Control · Individual
Zuelzke, James
Operational/Managerial Control · Individual
Zuelzke, James
Corporate Officer · Individual
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
The Windsor Place
Columbus, MS
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
#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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