Cycle 1
Health 2025-08-15 · Fire 2025-08-15
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Clinton, MS
Woodlands Rehabilitation And Healthcare Center
2-star overall rating with 2-star inspections with $35,648 in total fines with 10 recent health deficiencies
102 Woodchase Park Drive, Clinton, MS
(601) 924-7043
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
145
Certified beds
Average residents
132
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nexion Health
Operator or chain grouping
Approved since
1992-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
52 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 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
0.65
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.77
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.12
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
3.89
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,734
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.86
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
0
Baseline 20.07% · Performance 21.27% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.34
Baseline 9.18% · Performance 6.74% · Measure score 5.34 · Achievement 3.68 · Improvement 5.34
Total nurse turnover
3.65
Baseline 66.15% · Performance 48.99% · Measure score 3.65 · Achievement 3.59 · Improvement 3.65
Adjusted total nurse staffing
3.75
Baseline 4.62 hours · Performance 4.14 hours · Measure score 3.75 · Achievement 3.75 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.33% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 188 · Observed rate 13.3% · Lower 95% interval 8.67% |
| Discharge to community | 54.07% |
50.57%
3.5 pts better
|
No Different than the National Rate · Eligible stays 195 · Observed rate 43.08% · Lower 95% interval 45.27% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 63.08% |
95.27%
32.2 pts worse
|
Numerator 82 · Denominator 130 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 130 |
| Discharge self-care score | 45.45% |
53.69%
8.2 pts worse
|
Numerator 35 · Denominator 77 |
| Discharge mobility score | 35.06% |
50.94%
15.9 pts worse
|
Numerator 27 · Denominator 77 |
| Pressure ulcers or injuries, new or worsened | 3.08% |
2.29%
0.8 pts worse
|
Numerator 4 · Denominator 130 · Adjusted rate 2.26% |
| Healthcare-associated infections requiring hospitalization | 6.74% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 116 · Observed rate 7.76% · Lower 95% interval 4.29% |
| Staff COVID-19 vaccination coverage | 68.64% |
8.2%
60.4 pts better
|
Numerator 81 · Denominator 118 |
| Staff flu vaccination coverage | 14.65% |
42%
27.4 pts worse
|
Numerator 23 · Denominator 157 |
| Discharge function score | 58.44% |
56.45%
2 pts better
|
Numerator 45 · Denominator 77 |
| Transfer of health information to provider | 67.35% |
95.95%
28.6 pts worse
|
Numerator 33 · Denominator 49 |
| Transfer of health information to patient | 96.23% |
96.28%
About the same
|
Numerator 51 · Denominator 53 |
| Resident COVID-19 vaccinations up to date | 1.69% |
25.2%
23.5 pts worse
|
Numerator 1 · Denominator 59 |
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 2.2 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.9
1.7 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
95.7%
4 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.6% |
97.0%
2.4 pts worse
|
95.5%
0.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.2%
1.2 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.9% · Q3 3.1% · Q4 2.0% · 4Q avg 2.0% · 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 · 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 | 6.2% |
6.1%
0.1 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 8.2% · Q3 5.6% · Q4 2.1% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.3% |
24.4%
6.1 pts better
|
19.6%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 20.6% · Q3 17.4% · Q4 16.0% · 4Q avg 18.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.2% |
23.4%
11.2 pts better
|
16.7%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 12.3% · Q3 12.8% · Q4 12.5% · 4Q avg 12.2% · 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 · 4Q avg 32.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.0% |
20.6%
5.6 pts better
|
14.9%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 18.6% · Q3 22.8% · Q4 11.2% · 4Q avg 15.0% · 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 1.0% · Q2 0.7% · Q3 0.6% · Q4 1.3% · 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 1.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.2% |
21.4%
8.8 pts worse
|
19.8%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.3% · Q2 30.6% · Q3 34.9% · Q4 21.5% · 4Q avg 30.2% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
6.9%
1.2 pts better
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 7.9% · Q3 8.3% · Q4 3.1% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.1% |
87.9%
6.2 pts better
|
81.7%
12.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.3% · Q2 96.5% · Q3 93.1% · Q4 90.8% · 4Q avg 94.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.9% |
15.3%
6.4 pts better
|
12.0%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 10.4% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
2.6%
2.2 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.5% · Q3 0.5% · Q4 0.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.2% |
84.6%
6.6 pts better
|
79.7%
11.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 36.1% |
27.9%
8.2 pts worse
|
23.9%
12.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 36.1% · Observed 43.8% · Expected 28.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-11 · Fire 2024-04-11
14 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-07-14 · Fire 2022-07-14
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-07-14
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-08-15
F · Potential for more than minimal harm
2022-07-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-08-15
F · Potential for more than minimal harm
2022-07-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-15
D · Potential for more than minimal harm
2022-07-14
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2022-08-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-09
E · Potential for more than minimal harm
2025-08-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-08-15
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 2025-09-09
D · Potential for more than minimal harm
2025-08-15
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 2025-09-09
D · Potential for more than minimal harm
2025-08-15
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 2025-09-09
D · Potential for more than minimal harm
2025-08-15
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-08-15
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 2025-09-09
D · Potential for more than minimal harm
2025-08-15
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-08-15
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-09-09
J · Immediate jeopardy
2025-03-28
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 2025-03-26
J · Immediate jeopardy
2025-02-03
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 2025-01-01
J · Immediate jeopardy
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 2025-01-01
E · Potential for more than minimal harm
2024-09-25
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 2024-10-25
D · Potential for more than minimal harm
2024-09-25
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 2024-10-25
D · Potential for more than minimal harm
2024-09-25
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 2024-10-25
D · Potential for more than minimal harm
2024-09-25
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-10-25
G · Actual harm
2024-06-06
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 2024-06-19
G · Actual harm
2024-06-06
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
2024-04-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-04-11
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-04-11
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 2024-06-19
D · Potential for more than minimal harm
2024-04-11
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-04-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-04-11
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
2023-06-30
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 2023-08-11
D · Potential for more than minimal harm
2023-06-30
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 2023-08-11
D · Potential for more than minimal harm
2022-07-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-08-15
D · Potential for more than minimal harm
2022-07-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-08-15
D · Potential for more than minimal harm
2022-07-14
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 2022-08-15
Penalties and ownership
What sits behind the stars
$15,940
2025-03-28
Fine
Fine · fine $15,940
Fine
$5,598
2025-02-03
Fine
Fine · fine $5,598
Fine
$5,598
2025-02-03
Fine
Fine · fine $5,598
Fine
$8,512
2024-04-11
Fine
Fine · fine $8,512
Fine
Ownership
Nexion Health Of Ohi Inc
5% Or Greater Direct Ownership Interest · Organization
Bolt, Bretton
5% Or Greater Indirect Ownership Interest · Individual
Herdrich, William
Corporate Director · Individual
Kirley, Francis
5% Or Greater Indirect Ownership Interest · Individual
Kirley, Francis
Corporate Director · Individual
Kirley, Francis
Corporate Officer · Individual
Lee, Brian
Corporate Director · Individual
Lee, Brian
Corporate Officer · Individual
Nexion Health Leasing, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Nexion Health, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Nexion Health, Inc.
Operational/Managerial Control · Organization
Pope, Jennifer
W-2 Managing Employee · Individual
Reid, John
Corporate Director · Individual
Riner, Meera
Corporate Director · Individual
Riner, Meera
Corporate Officer · Individual
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#3
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