Home / Mississippi / Madison
111 Kelly Blvd, Madison, MS 39110 · Madison County · (601) 355-0763
60 certified beds, about 58 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 2001
CMS Care Compare ratings, data as of September 1, 2026 · CCN 255276 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on January 16, 2025, inspectors cited 8 health deficiencies (the Mississippi average is 6.8, the national average 9.2).
None of its 25 health citations since April 2022 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 4.62 hours per resident per day, against 4.18 across Mississippi and 3.86 nationally. Registered nurses accounted for 0.67 of those hours.
58.9% of nursing staff left within the year CMS measured (Mississippi average 45.7%).
CMS links it to Trend Consultants, an affiliated group of 15 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 25 health citations on file.
Inspectors wroteBased on observation, record review, staff interviews, and facility policy review, the facility failed to implement and maintain an effective infection prevention and control program for one (1) of three (3) residents reviewed for infection control practices. (Resident #2)Findings Include: Record review of the facility policy Enhanced Barrier Precautions dated 10-23 revealed, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms . Record review of the facility policy Hand Hygiene Policy dated 5-25 revealed, .6. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. During an observation on 05/26/26 at 2:35 PM, Resident #2 was observed receiving incontinent care. [...]
Inspectors wroteBased on observation, record review, facility policy review and staff interviews, the facility failed to ensure staff followed the plan of care related to Enhanced Barrier Precautions (EBP) during high contact resident care for one (1) of three (3) residents reviewed for infection prevention practices. (Resident #2). Findings Include: Record review of the facility policy Following the Care Plan Policy date 1/2011 revealed, Policy: It is the policy of this facility to follow a written and approved care plan for each resident. All employees will be.required to follow the care plan. A record review of the Care Plan Report revealed Focus: Resident has pressure ulcer. Interventions/Tasks. Enhanced barrier precautions, follow facilities protocol. [...]
Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure physician ordered Negative Pressure Wound Therapy (NPWT) was monitored and maintained in working order for one (1) of three (3) residents reviewed for wound care. Resident #2. Findings Include: Record review of the facility policy Negative Pressure Wound Therapy (NPWT) dated 7/2025 revealed, .9. Monitoring throughout the use of NPWT shall include, but is not limited to, the following: a. Pain associated with the therapy. b. Device is functioning. c. Settings as prescribed. d. Troubleshooting of any alarms, in accordance with pump/product specifications. e. Response of the therapy, including wound characteristics and progress towards healing . [...]
Inspectors wroteBased on record review, facility policy review, and staff and resident interviews, the facility failed to prevent the misappropriation of property, specifically scheduled medication, for one (1) of four (4) sampled residents, Resident #1. Findings Included:Record review of the facility's Abuse Policy and Procedure with Review/Revision Date 1/24/22 revealed, Each resident of this facility has the right to be free from verbal, sexual, physical and mental abuse, involuntary seclusion, corporal punishment, neglect and or misappropriation of resident property.7. 'Misappropriation of resident property' means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent . [...]
Inspectors wroteBased on observations, staff interviews, and facility policy review the facility failed to ensure items in the walk-in kitchen refrigerator were labeled and dated, discarded by the expiration date, and arranged in a manner to prevent possible cross-contamination for one (1) of three (3) kitchen tours
Inspectors wroteBased on resident and staff interview, record review, and facility policy review, the facility failed to honor resident's rights to make health care decisions for three (3) of 24 residents reviewed for advanced directives. Resident #10, #36, and #48 Findings Include: Record review of the facility policy titled Do Not Resuscitate No Code Status Policy dated 2/2024 revealed, It is the policy of this facility to inform residents of the right to choose to have CPR (cardiopulmonary resuscitation) or no CPR to be performed at such time of imminent death. The code status form will be completed at the time of admission. Resident #10 Record review of Resident #10's Order Summary Report revealed, DNR (Do Not Resuscitate): Need for death with dignity related to choice of code status DNR per family/Resident Representative (RR) request. [...]
Inspectors wroteBased on staff interview and record review, the facility failed to accurately code section A of the Minimum Data Set (MDS) for a resident with a serious mental illness for one (1) of 16 MDS reviewed. Resident #16 Findings Include: The facility provided a statement on letterhead dated 1/15/25 that read, It is the policy of Proper Name of the Facility to follow the RAI (Resident Assessment Instrument) manual for completion and accuracy of the MDS (Minimum Data Set) assessments. Record review of Resident #16's Preadmission Screening and Resident Review (PASRR) Summary of Findings Report dated 6/14/2017, revealed under, Mental Health . The individual meets criteria for having a diagnosis of mental illness as defined by PASRR. Also revealed under, Axis I primary: Schizophrenia was listed as the diagnosis. [...]
Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for personal hygiene.(Resident #1, #2, #7) and adaptive equipment with meals (Resident #2) for three (3) of 16 care plans reviewed. Residents #1, # 2, #7 Findings Include: Review of the facility policy titled, Following the Care Plan Policy unrevised, revealed under, Policy: It is the Policy of this facility to follow a written and approved care plan for each resident. Resident #1 Record review of Resident #1's ADL (activities of daily living) Care Plan revealed under, Focus: The resident has an ADL self-care performance deficit r/t (related to) Dementia. Also revealed under, Intervention/Task: Personal hygiene/Oral care: The resident requires x (times) 1 (one) staff participation with personal hygiene . [...]
Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide nail care, oral care and facial hair removal for resident's requiring assistance with activities of daily living (ADLs) for three (3) of 16 sampled residents. Resident #1, #2, and #7 Findings Include: Record review of the facility policy, ADL Care Policy undated, revealed, It is the policy of this facility to provide appropriate treatment and services in relation to ADL care to residents to ensure all ADL needs are met on a daily basis . Resident #1 An observation and interview on 1/14/25 at 9:20 AM revealed, Resident #1 with facial hair on her chin that was approximately three (3) to four (4) inches long. An interview with the resident revealed that she did not like facial hair and stated, I want them gone. [...]
Inspectors wroteBased on observation, staff and resident interviews, and facility policy review, the facility failed to properly store medications, as evidenced by, medications left in a resident's room for one (1) of 16 sampled residents. Resident #41 Findings Include: Record review of the facility policy Medication Storage dated 01/2024, revealed It is the policy of this facility to ensure all medications housed on our premises will be stored in the medication cart and/or medication rooms according to the manufacturer's recommendation An observation on 1/14/25 at 11:00 AM and 2:00 PM revealed a one-ounce bottle of lubricant eye drops and a two-ounce tube of pain relief cream on the overbed table in Resident #41's room. An interview on 1/14/25 at 2:50 PM, with Resident #41 revealed he brought his eye drops and pain cream from home, and he applied them himself. [...]
Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to provide a resident with adaptive equipment during meals for one (1) of two (2) dining observations. Resident #2 Findings Include: Review of the facility policy titled Assistive Feeding Devices with a revision date of 6/14 revealed under, Policy: Residents shall be provided assistive devices to maintain or improve their ability to eat independently. Also revealed under, Procedure: . 4. The assistive devices are placed on the resident's tray at the time of meal service. An observation on 1/14/25 at 11:55 AM revealed Resident #2's lunch meal was served on a regular plate with a goblet glass of tea and water with a meal ticket that read, Divided plate, sippy cup. [...]
Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to follow Enhanced Barrier Precautions (EBP) while providing resident care for two (2) of three (3) direct care observations. Resident #28 and Resident #49 Findings Include: Record review of the facility policy Enhanced Barrier Precautions with a revised date of 8/07/24, revealed under, Policy Explanation and Compliance Guidelines: . 2. Initiation of Enhanced Barrier Precautions: . b. An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds . and/or indwelling medical devices ( .urinary catheters, feeding tubes .) even if the resident is not known to be infected . [...]
Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to safely store and lock hazardous cleaning chemicals on four (4) of five (5) housekeeping carts observed during annual survey.
Inspectors wroteBased on observation, facility policy review, and staff interviews, the facility failed to prevent possible food contamination as evidenced by observations during the initial kitchen tour of improper thawing of raw chicken and three (3) and one-half (1/2) loaves of expired sliced sandwich bread, for 51 of 53 residents receiving dietary trays.
Inspectors wroteBased on observation, staff interview, record review, and facility policy review the facility failed to prevent the possible spread of COVID-19 as evidenced by failure to fully implement their policy to ensure that all staff are fully vaccinated or received an exemption for two (2) of 97 employee records reviewed. Findings Include: Record review of the facility policy titled, Employee COVID-19 Vaccinations undated, revealed It is the policy of this facility to ensure that all eligible employees are vaccinated against COVID-19 as per applicable Federal, State and local guidelines . Compliance Guidelines: 1. The facility will ensure that all eligible employees are fully vaccinated against COVID-19, unless religious or medical exemptions are granted. 2. [...]
Inspectors wroteBased on observations, staff interviews, record reviews, and facility policy review the facility failed to provide a sufficient volume level on the resident call light system as evidenced by the inability to hear the call light system alarm on the nursing unit halls for four (4) of 4 days of survey.
Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to utilize assistive devices available to maintain resident's communication abilities for three of four survey days. Resident #20.
Inspectors wroteBased on observation, staff interviews, resident interviews, record review, and facility policy review, the facility failed to ensure that each resident was treated with dignity as evidenced by failure to provide verbal communication to residents during care, knock on resident's door before entering, cover a resident and close door during care, and failure to provide a privacy bag for a catheter for 4 of 24 residents observed. Resident #19, #27, #42, #43. Findings Include Resident #27 Review of the facility policy titled, Promoting/Maintaining Resident Dignity with a revision date of 1-19, revealed, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. [...]
Inspectors wroteBased on facility policy review, record reviews, and staff interviews, the facility failed to complete a Preadmission Screening (PAS) Level One (I) Assessment for a resident for one (1) of two (2) residents reviewed for Preadmission Screening and Resident Review (PASARR).
Inspectors wroteBased on facility policy review, record reviews, and staff interviews, the facility failed to complete a Change in Status Form to generate a request for a Preadmission Screening and Resident Review (PASRR) Level Two (II) Assessment, for a resident with a mental status change, for one of two residents reviewed for PASRR. Resident #34.
Inspectors wroteBased on observation, staff interviews, record review and facility policy review, the facility failed to develop and implement comprehensive care plans for three (3) of 24 residents reviewed for care plans, Resident #19, Resident #20 and Resident #42.
Inspectors wroteBased on observation, staff and resident interviews, facility policy review and record review, the facility failed to provide personal hygiene as evidenced by long and jagged nails and flecks of white material in resident's hair for 2 of 24 residents observed. Residents #42 and Resident #19.
Inspectors wroteBased on observation, resident interviews, staff interviews, record review, and facility policy review, the facility failed to ensure a resident who was at risk for wandering was appropriately monitored and supervised to prevent wandering into other residents' rooms for one (1) of four (4) survey days. Resident #46.
Inspectors wroteBased on observation, staff interview, record review and facility policy review the facility failed to label and date a tube feeding for one (1) of four (4) residents observed. Resident #5 Findings Include A review of the facility policy titled, Labeling of Enteral Feeding Supplies/Containers with a revision date of 4/20/19 revealed, It is the policy of this facility that all enteral feeding bottles/bags will be labeled with the rate of feeding, date bottle/bag began and initials of the nurse initiating as well as the feeding formula listed. An observation on 04/04/22 at 11:38 AM, revealed Resident #5 had a Percutaneous Endoscopic Gastrostomy (PEG) feeding tube connected to a continuous feeding pump. [...]
Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to provide a proper barrier during medication administration and failed to ensure a catheter bag was properly positioned for three (3) of five (5) residents observed during medication pass and catheter observations. Unsampled Resident #1, Resident #33 and Resident #42
1 fire safety citation on file: 1 on April 7, 2022.
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Mississippi | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.62 | 4.18 | 3.86 |
| Registered nurses | 0.67 | 0.64 | 0.69 |
| All nursing staff on weekends | 3.55 | 3.50 | 3.42 |
| Nurse aides | 2.53 | ||
| Licensed practical nurses | 1.43 | ||
| Nursing staff turnover (share who left in a year) | 58.9% | 45.7% | 45.8% |
| Registered nurse turnover | 50.0% | 38.5% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.22 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 5.06 on weekdays and 3.55 on weekends, 30% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 5.14 in April to June 2025 to 4.62 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.62 | 0.67 | 5.06 | 3.55 | 0.0% | 0 of 90 | 58 |
| Oct to Dec 2025 | 4.96 | 0.71 | 5.39 | 3.83 | 0.0% | 0 of 92 | 58 |
| Jul to Sep 2025 | 5.13 | 0.71 | 5.63 | 3.84 | 0.0% | 0 of 92 | 57 |
| Apr to Jun 2025 | 5.14 | 0.74 | 5.49 | 4.24 | 0.0% | 0 of 91 | 57 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Mississippi, Jan to Mar 2026 | 4.09 | 0.60 | 4.35 | 3.44 | 6.2% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Mississippi, all employers | |||
| CNAs (nursing assistants) | $15.15 | $14.19 to $16.92 | 14,200 |
| LPNs and LVNs | $24.14 | $22.50 to $27.90 | 9,850 |
| Registered nurses | $37.06 | $31.22 to $40.62 | 29,060 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Mississippi | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 6.9 | 20.5 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 2.1 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 7.0 | 2.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.0 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.9 | 2.5 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 7.8 | 19.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 2.0 | 6.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 27.8 | 21.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 20.7 | 27.7 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 8.7 | 15.5 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.6 | 2.4 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.8 | 2.9 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for The Madison Health and Rehab's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (58.8% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
58.8% this home
Better than the national rate
US median of homes 51.5% · Mississippi: 21 better, 14 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 357 eligible stays.
10.4% this home
No different from the national rate
US median of homes 10.7% · Mississippi: 1 better, 10 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 329 eligible stays.
6.6% this home
No different from the national rate
US median of homes 7.1% · Mississippi: 1 better, 3 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 242 eligible stays.
73.2% this home
Median of homes: Mississippi52.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 231 residents counted.
0.0% this home
Median of homes: Mississippi0.7% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 285 residents counted.
1.1% this home
Median of homes: Mississippi2.8% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 285 residents counted.
97.1% this home
Median of homes: Mississippi98.3% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 208 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: BELHAVEN SENIOR CARE. CMS links this home to Trend Consultants, a group of 15 nursing homes averaging 3.3 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Kelly, Charles | Direct ownership interest | Individual | 08/01/2007 | |
| Kelly, Rita | Corporate director | Individual | 08/01/2007 | |
| Warnock, Lori | Corporate director | Individual | 01/27/2024 | |
| Trend Consultants LLC | Operational/managerial control | Organization | 08/01/2007 | |
| Kelly, Charles | Operational/managerial control | Individual | 12/01/2004 | |
| Trend Consultants LLC | Adp of the SNF | Organization | 01/02/2025 | |
| Warnock, Lori | Adp of the SNF | Individual | 01/24/2024 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Mississippi. NursingHomeClear cannot take or act on complaints.