Cycle 1
Health 2025-02-20 · Fire 2025-02-20
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Pearl, MS
Wisteria Gardens
4-star overall rating with 3-star inspections with 6 recent health deficiencies
5420 Highway 80 East, Pearl, MS
(601) 988-6800
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
52
Certified beds
Average residents
45
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2008-03-31
CMS approved date
Coverage
Medicare
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
0.75
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.15
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
3.29
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
5.18
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.90
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
4.31
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.23
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
5.67
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
60%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,786
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.71
Composite VBP score used to determine payment impact.
Payment multiplier
0.9867
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.41
Baseline 21.64% · Performance 20.78% · Measure score 1.41 · Achievement 1.41 · Improvement 1.37
Healthcare-associated infections
2.90
Baseline 6.54% · Performance 6.97% · Measure score 2.90 · Achievement 2.90 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
5.21
Baseline 4.26 hours · Performance 4.56 hours · Measure score 5.21 · Achievement 5.21 · Improvement 1.46
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.86% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 736 · Observed rate 7.34% · Lower 95% interval 7.93% |
| Discharge to community | 62% |
50.57%
11.4 pts better
|
Better than the National Rate · Eligible stays 765 · Observed rate 62.88% · Lower 95% interval 59.39% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.34% |
95.27%
4.1 pts better
|
Numerator 455 · Denominator 458 |
| Falls with major injury | 1.09% |
0.77%
0.3 pts worse
|
Numerator 5 · Denominator 458 |
| Discharge self-care score | 74.29% |
53.69%
20.6 pts better
|
Numerator 260 · Denominator 350 |
| Discharge mobility score | 66.86% |
50.94%
15.9 pts better
|
Numerator 234 · Denominator 350 |
| Pressure ulcers or injuries, new or worsened | 2.62% |
2.29%
0.3 pts worse
|
Numerator 12 · Denominator 458 · Adjusted rate 3.65% |
| Healthcare-associated infections requiring hospitalization | 6.97% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 458 · Observed rate 5.46% · Lower 95% interval 4.77% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 80 |
| Staff flu vaccination coverage | 15.73% |
42%
26.3 pts worse
|
Numerator 14 · Denominator 89 |
| Discharge function score | 68.29% |
56.45%
11.8 pts better
|
Numerator 239 · Denominator 350 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 117 · Denominator 117 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 332 · Denominator 332 |
| Resident COVID-19 vaccinations up to date | 8.18% |
25.2%
17 pts worse
|
Numerator 18 · Denominator 220 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
6.1%
2.5 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.2% |
24.4%
7.2 pts better
|
19.6%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.2% |
| 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.9% |
20.6%
13.7 pts better
|
14.9%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.3% |
1.5%
0.8 pts worse
|
1.0%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.1% |
2.5%
4.6 pts worse
|
1.7%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.2% |
21.4%
7.8 pts worse
|
19.8%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.2% |
| Percentage of long-stay residents with pressure ulcers | 11.5% |
6.9%
4.6 pts worse
|
5.1%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
87.9%
11.8 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 99.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.4% |
15.3%
6.9 pts better
|
12.0%
3.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.4% · Observed 7.7% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
2.6%
1.1 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.6% · Q3 2.5% · Q4 1.7% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.6% |
84.6%
15 pts better
|
79.7%
19.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.0% |
27.9%
0.1 pts worse
|
23.9%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.0% · Observed 22.1% · Expected 18.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-19 · Fire 2023-10-19
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-09-10 · Fire 2021-09-10
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-10-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-06
D · Potential for more than minimal harm
2021-09-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-10-15
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-20
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 2025-03-21
E · Potential for more than minimal harm
2025-02-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-20
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 2025-03-21
D · Potential for more than minimal harm
2025-02-20
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-21
F · Potential for more than minimal harm
2023-10-19
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 2023-11-30
D · Potential for more than minimal harm
2023-10-19
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-11-30
C · Minimal harm
2023-10-19
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-11-30
D · Potential for more than minimal harm
2021-09-10
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 2021-10-27
D · Potential for more than minimal harm
2021-09-10
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 2021-10-27
D · Potential for more than minimal harm
2021-09-10
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-10-27
D · Potential for more than minimal harm
2021-09-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-10-27
D · Potential for more than minimal harm
2021-09-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-10-27
Penalties and ownership
What sits behind the stars
Ownership
Ashley Healthcare, Inc
5% Or Greater Direct Ownership Interest · Organization
Albert, Michael
Contracted Managing Employee · Individual
Ashley Management, LLC
Operational/Managerial Control · Organization
Galloway, Charles
5% Or Greater Indirect Ownership Interest · Individual
Hill, William
5% Or Greater Indirect Ownership Interest · Individual
Hill, William
W-2 Managing Employee · Individual
Kickapoo Properties LLC
5% Or Greater Indirect Ownership Interest · Organization
M-D Transportation LLC
5% Or Greater Indirect Ownership Interest · Organization
Maxey, John
5% Or Greater Indirect Ownership Interest · Individual
Mccay, David
5% Or Greater Indirect Ownership Interest · Individual
Shelton, Rebecca
Corporate Officer · Individual
Signature Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Town Creek Company LLC
5% Or Greater Indirect Ownership Interest · Organization
Walker, Ben
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
Other facilities in reach
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Brandon Community Care Center
Brandon, MS
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $97,553 in total fines with 20 recent health deficiencies
#2
Brandon Court
Brandon, MS
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#3
Jnh-Jaquith Inn
Whitfield, MS
5-star overall rating with 5-star inspections with 1 recent health deficiencies
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