Cycle 1
Health 2025-08-07 · Fire 2025-08-07
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
West Point, MS
West Point Community Living Center
1-star overall rating with 1-star inspections with abuse icon flag with $76,557 in total fines with 10 recent health deficiencies
2056 N Eshman Avenue, West Point, MS
(662) 494-6011
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
55
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Community Eldercare Services
Operator or chain grouping
Approved since
1989-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 2 overall / 2 health / 3 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
0.48
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.58
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
3.93
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
4.69
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,930
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.95
Composite VBP score used to determine payment impact.
Payment multiplier
1.0076
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
5.92
Baseline 100.00% · Performance 51.77% · Measure score 5.92 · Achievement 2.91 · Improvement 5.92
Adjusted total nurse staffing
4.67
Baseline 3.93 hours · Performance 4.41 hours · Measure score 4.67 · Achievement 4.67 · Improvement 2.09
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.61% |
10.72%
2.9 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 31.43% · Lower 95% interval 9.02% |
| Discharge to community | 49.83% |
50.57%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 25 · Observed rate 40% · Lower 95% interval 31.39% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 25 · Denominator 25 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 25 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 4% |
2.29%
1.7 pts worse
|
Numerator 1 · Denominator 25 · Adjusted rate 3.49% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 13.33% |
8.2%
5.1 pts better
|
Numerator 10 · Denominator 75 |
| Staff flu vaccination coverage | 60% |
42%
18 pts better
|
Numerator 45 · Denominator 75 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
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 2.2 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.9
1.5 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 65.5% |
95.7%
30.2 pts worse
|
93.4%
27.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 73.8% · Q2 57.4% · Q3 63.8% · Q4 67.3% · 4Q avg 65.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.6% |
97.0%
12.4 pts worse
|
95.5%
10.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.2%
1.5 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.3% · Q3 0.0% · Q4 1.8% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
1.6%
1.1 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 10.4% |
6.1%
4.3 pts worse
|
5.4%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 12.5% · Q3 10.4% · Q4 10.4% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.6% |
24.4%
3.8 pts better
|
19.6%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 17.5% · Q3 23.1% · Q4 22.4% · 4Q avg 20.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 45.3% |
23.4%
21.9 pts worse
|
16.7%
28.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.8% · Q2 47.2% · Q3 42.4% · Q4 47.2% · 4Q avg 45.3% · 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 | 25.5% |
22.8%
2.7 pts worse
|
16.3%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.2% |
20.6%
7.6 pts worse
|
14.9%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.2% · Q2 27.7% · Q3 20.0% · Q4 23.9% · 4Q avg 28.2% · 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 4.4% · Q2 1.5% · Q3 0.0% · Q4 2.6% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
2.5%
1.6 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.6% |
21.4%
5.2 pts worse
|
19.8%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.0% · Q2 21.7% · Q3 26.5% · Q4 23.3% · 4Q avg 26.6% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
6.9%
2.5 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.5% · Q3 5.0% · Q4 6.7% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 7.5% |
87.9%
80.4 pts worse
|
81.7%
74.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 8.8% · Q3 6.7% · Q4 4.3% · 4Q avg 7.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.5% |
15.3%
0.8 pts better
|
12.0%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.5% · Observed 16.7% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.5% |
2.6%
1.9 pts worse
|
1.6%
2.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 4.2% · Q3 3.3% · Q4 3.0% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 20.6% |
84.6%
64 pts worse
|
79.7%
59.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 20.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.9% |
27.9%
14 pts better
|
23.9%
10 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 13.3% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-04 · Fire 2024-01-04
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-06-23 · Fire 2022-06-23
6 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
K · Immediate jeopardy
2025-08-07
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 2025-09-10
G · Actual harm
2025-08-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-09-10
E · Potential for more than minimal harm
2025-08-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-08-07
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-08-07
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 2025-09-10
D · Potential for more than minimal harm
2025-08-07
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-08-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-08-07
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-04-08
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-02-03
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 2024-11-08
D · Potential for more than minimal harm
2024-03-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-20
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 2024-04-29
D · Potential for more than minimal harm
2024-01-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-06
G · Actual harm
2023-03-23
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 2023-04-21
G · Actual harm
2023-03-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-21
E · Potential for more than minimal harm
2023-03-23
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 2023-04-21
E · Potential for more than minimal harm
2023-03-23
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-04-21
E · Potential for more than minimal harm
2022-06-23
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 2022-07-16
D · Potential for more than minimal harm
2022-06-23
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 2022-07-16
Penalties and ownership
What sits behind the stars
$69,035
2025-08-07
Fine
Fine · fine $69,035
Fine
$7,522
2023-03-23
Fine
Fine · fine $7,522
Fine
Ownership
Community Living Centers, LLC
5% Or Greater Direct Ownership Interest · Organization
Wright, Douglas
5% Or Greater Indirect Ownership Interest · Individual
Community Eldercare Services, LLC
Operational/Managerial Control · Organization
Ostrander, Troy
Operational/Managerial Control · Individual
Spence, Deborah
Operational/Managerial Control · Individual
Wright, Douglas
Operational/Managerial Control · Individual
Nearby options
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#2
Vineyard Court Nursing Center
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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
#3
Care Center Of Aberdeen
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2-star overall rating with 2-star inspections with $10,358 in total fines with 9 recent health deficiencies
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