Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Great Oaks Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident’s MDS assessments were not completed within CMS-required time frames. The Discharge, Entry Tracking, and Annual MDSs were all signed late, and the MDS Nurse confirmed the delays were due to recent staff changes in the MDS dept. The Administrator stated the facility had no policy for timely MDS encoding and transmission and staff relied on the RAI Manual for guidance. The resident had asthma with acute exacerbation and Parkinson’s disease, and the annual MDS showed a BIMS score of 15.
A resident with significant cognitive impairment and multiple medical conditions returned from a hospital stay without previously ordered interventions, such as an abduction pillow and nutritional supplement, being reinstated. Facility staff did not contact the provider to clarify whether these interventions should be resumed, and there was no policy guiding the review or transcription of readmission orders, resulting in a lapse in continuity of care.
A resident with cognitive impairment and dependent mobility was found to have bilateral femoral neck fractures of unknown origin. The facility's investigation was inconclusive and lacked key documentation, yet the incident was not reported to the State Agency as required by policy, due to the belief that the injuries were pathological.
A resident who was cognitively impaired and dependent for transfers sustained bilateral femoral neck fractures and facial bruising, with the injuries not identified until a later hospital visit. The facility's investigation into the injuries was incomplete, lacking staff witness statements, comprehensive documentation, and timely communication with the responsible party, resulting in an inability to determine the cause of the injuries.
A verified therapy order for a resident with multiple medical conditions and cognitive impairment was not entered into the electronic medical record after being reviewed and signed by an NP. As a result, the ordered therapy services were not initiated, and the resident's clinical record was incomplete. The DON and administrator confirmed the lack of documentation and absence of a policy for transcribing orders into the system.
A resident with a history of falls and moderate cognitive impairment suffered a head laceration requiring ER treatment after staff removed bed rails without a safety assessment or alternative interventions. The resident rolled out of bed during care, and staff confirmed no individualized assessment or additional safety measures were implemented following the removal of the rails.
The facility experienced significant staffing shortages, particularly during night shifts, leading to delayed responses to resident needs. The DON and ADON often covered shifts themselves due to high staff turnover and frequent call-ins. Residents reported long wait times for assistance, with some waiting over an hour for call lights to be answered. The facility's staffing grid confirmed insufficient CNA coverage, despite a census of fifty residents, many requiring two-person assistance. The Administrator believed staffing was adequate, despite resident complaints.
A CNA in an LTC facility misappropriated a resident's funds by using her debit card without permission to order food for herself. The resident initially allowed the CNA to use her card due to a lack of access to a food app, but the CNA continued unauthorized use, leading to multiple charges. The resident's husband discovered a pending charge, prompting an investigation that revealed the CNA's actions. Despite training on abuse and misappropriation, the CNA violated policy, resulting in financial exploitation.
A resident's Hydrocortisone medication was discontinued by the FNP based on a pharmacist's recommendation without notifying the resident's representative (RR). The facility's policy required such notifications, but the ADON assumed the FNP would address it later. The medication was reinstated after the RR explained its importance.
Late MDS Assessment Completion and Transmission
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were completed and transmitted within CMS-required time frames for one resident reviewed. Record review showed that the resident’s Discharge MDS with an ARD of 12/16/25 was signed as completed on 1/19/26, and the Final Validation Report identified the assessment as completed late because the completion date was more than 14 days after the ARD. The resident’s Entry Tracking Record with an ARD of 12/23/25 was also signed as completed on 1/15/26, indicating late completion, and the resident’s Annual Assessment with an ARD of 4/14/26 was signed as completed on 4/29/26, which was also late. During interview, the MDS Nurse confirmed the resident’s Discharge, Entry, and Annual assessments were not completed timely and stated recent staff changes in the MDS department delayed timely completion of assessments. The Administrator stated the facility did not have a policy regarding timely encoding and transmission of MDS assessments and that staff followed the RAI Manual for guidance. The resident had been re-admitted with diagnoses including unspecified asthma with acute exacerbation and Parkinson’s disease without dyskinesia, and the MDS for the annual assessment showed a BIMS score of 15, indicating the resident was cognitively intact.
Failure to Clarify and Resume Pre-Hospital Interventions After Readmission
Penalty
Summary
The facility failed to notify the provider to clarify missing orders for previously established interventions after a resident returned from the hospital. Prior to hospital transfer, the resident had orders for an abduction pillow and a nutritional supplement, but these were not mentioned in the hospital's After Visit Summary upon readmission. The facility did not contact the provider to determine if these interventions should be resumed, resulting in the interventions not being reinstated. Interviews with the ADON, DON, and the Administrator confirmed that no clarification was sought regarding the continuation of these interventions, and there was no policy in place for reviewing or transcribing readmission orders to address such situations. The resident involved was admitted with multiple diagnoses, including malignant neoplasm of the cervix, protein-calorie malnutrition, vitamin D deficiency, and bilateral femoral neck fractures. The resident was cognitively impaired, with a BIMS score of 1, and was dependent for transfers and non-ambulatory. The lapse in continuity of care occurred because the facility did not verify whether to continue previously established interventions following the resident's return from the hospital.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency as required by its Abuse Prohibition Policy. The policy mandates that the Abuse Coordinator report injuries of unknown source with serious bodily injury within two hours of the allegation. In this case, a resident with significant cognitive impairment and dependent for transfers was found to have bilateral displaced femoral neck fractures, which were identified during a hospital evaluation for seizure-like activity. The investigation into the cause of the fractures was inconclusive, with possible causes including a pathological process, seizure activity, or a rough transfer by EMS, as reported by the resident's responsible party. Despite the inability to determine the cause of the fractures, the facility did not report the incident to the State Agency, believing the injuries to be pathological. The investigation file lacked documentation such as staff witness statements, records of conversations with the responsible party prior to the injury, and supporting evidence for the conclusion that the fractures were pathological. The administrator later acknowledged that the cause could not be determined and that the incident met the definition of an injury of unknown origin that should have been reported.
Failure to Promptly and Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a prompt and thorough investigation into an injury of unknown origin for one resident. The resident, who was cognitively impaired and dependent for transfers, experienced a syncopal episode and was transferred to the ER. Later, the responsible party reported that EMS had not been gentle during the transfer, and the resident had cried out in pain. However, the facility's investigation lacked documentation of staff witness statements, did not include a record of conversation with the responsible party prior to the injury, and did not provide supporting documentation for the conclusion that the fractures were pathological. The investigation summary listed possible causes, including a pathological process, seizure activity, or rough EMS transfer, but did not contain comprehensive evidence or interviews to support these conclusions. The injury, specifically bilateral femoral neck fractures, was not identified until a later hospital visit for evaluation of seizure-like activity. Progress notes indicated facial bruising without a reported history of trauma, and imaging revealed the fractures may have been subacute. The administrator acknowledged that the investigation was incomplete, as staff were not asked for written statements and there was no information regarding events leading up to the hospital transfer or current hospital documentation. The responsible party also reported that the facility did not provide information about the cause of the injuries during care plan meetings.
Failure to Enter Verified Therapy Orders Resulting in Incomplete Medical Record
Penalty
Summary
A deficiency occurred when a verified exercise order for a resident was not entered into the electronic medical record, resulting in an incomplete clinical record. The order, provided by the resident's orthopedic physician, specified passive exercises for the lower extremities and active range of motion for the upper extremities due to the resident's non-weight bearing status. Although the nurse practitioner reviewed and signed off on the order, it was not transcribed into the computer system, and as a result, the ordered therapy services were not initiated. Review of the resident's physician orders for the relevant month confirmed the absence of documentation for the new exercises. The Director of Nursing confirmed that nurse practitioners are responsible for entering their own orders into the system and acknowledged that the resident's medical record did not accurately reflect all current orders. The facility administrator also verified that there was no policy in place for transcribing orders into the electronic system. The affected resident had a history of malignant neoplasm of the cervix, protein-calorie malnutrition, vitamin D deficiency, and bilateral femur fractures, and was cognitively impaired and dependent for transfers, with no ambulation.
Failure to Assess and Implement Safety Measures After Bed Rail Removal
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision and equipment to prevent accidents for one of four sampled residents. Staff removed the resident's bed rails without conducting a safety assessment, despite documentation indicating a history of falls from bed and a care plan that included the use of partial bed rails at all times. No assessment was completed to determine if the resident would be safe without the bed rails, and no alternative safety interventions were implemented at the time of removal. The resident, who had diagnoses including chronic obstructive pulmonary disease, muscle wasting and atrophy, repeated falls, and required assistance with personal care, was moderately cognitively impaired. During care, the resident rolled out of bed after the bed rails had been removed, sustaining a head laceration that required emergency room treatment, including x-rays and stitches. Staff interviews confirmed that the resident previously used the bed rails for assistance with turning and that their removal was based on a facility-wide policy change, not on an individualized assessment. Observations and interviews revealed that the resident was being assisted by a CNA at the time of the fall, who turned the resident and then reached for supplies, during which the resident rolled off the bed. The incident resulted in a significant injury, and it was confirmed by the DON and other staff that no side rail assessment was completed at the time of removal and no other safety measures were put in place to prevent injury after the bed rails were taken off.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, as evidenced by interviews with staff and residents, and a review of facility records. The Director of Nursing (DON) and other staff members reported significant staffing shortages, particularly during night shifts, which resulted in delayed responses to resident needs. The DON and Assistant Director of Nursing (ADON) were often required to cover shifts themselves due to high staff turnover and frequent call-ins, leading to exhaustion and a feeling of being overwhelmed. Residents reported long wait times for assistance, particularly at night, with some waiting over an hour for call lights to be answered. This delay in care was particularly concerning for residents who required assistance with personal care and transfers, as many residents needed two-person assistance. The facility's staffing grid confirmed that there were often only two CNAs working during night shifts, despite a census of fifty residents, many of whom required significant assistance. The facility's staffing issues were exacerbated by a lack of incentives for staff to work extra shifts, as bonuses had been reduced. The facility had several open CNA positions and was unable to retain new hires due to the heavy workload. Despite the DON's efforts to address staffing concerns, the Administrator believed that staffing was adequate and was unaware of resident complaints. The facility's failure to maintain sufficient staffing levels resulted in compromised resident care and unmet needs.
Misappropriation of Resident's Funds by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property, as evidenced by the actions of a Certified Nursing Assistant (CNA). The CNA used the resident's debit card without permission to order food for herself and the resident, resulting in unauthorized charges. The resident initially allowed the CNA to use her debit card to order food due to a lack of access to a food ordering application. However, the CNA continued to use the card without the resident's consent, leading to multiple unauthorized transactions. The resident's husband discovered a pending charge on their bank account, which prompted an investigation. It was revealed that the CNA had saved the resident's debit card information on her phone and used it to make personal purchases. The CNA also asked the resident to buy her lunch, promising to pay her back, but failed to do so until confronted. The investigation uncovered additional unauthorized charges, including a subscription fee linked to the CNA's email address, which the resident did not approve. Interviews with staff and the resident confirmed the misappropriation of funds. The CNA admitted to using the resident's debit card and acknowledged that she knew it was against policy. Despite receiving training on abuse, neglect, and misappropriation of property, the CNA violated the resident's rights by misusing her financial information. The facility's policies clearly prohibit such actions, yet the CNA disregarded these guidelines, resulting in a breach of trust and financial exploitation of the resident.
Failure to Notify Resident's Representative of Medication Change
Penalty
Summary
The facility failed to notify the resident's representative (RR) of a change in medication for a resident who had been on Hydrocortisone and Desmopressin since 1980 due to Diabetes Insipidus. The Family Nurse Practitioner (FNP) at the facility discontinued Hydrocortisone based on a pharmacist's recommendation without informing the RR. The RR later explained the importance of the medication, leading to its reinstatement. The facility's policy required notifying the RR of any significant changes, including medication changes, but this protocol was not followed in this instance. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the FNP revealed that the decision to discontinue Hydrocortisone was made after a pharmacist highlighted a potential drug interaction. However, the ADON admitted that they failed to notify the RR about the medication change, assuming the FNP would address it during rounds the next day. The resident's progress notes and medication administration records confirmed the discontinuation and subsequent reinstatement of Hydrocortisone after the RR's intervention.
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Illustrative
What surveyors actually found near you
We read the 166 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Byhalia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Collierville Nursing And Rehabilitation, Llc | 12.5 mi | ★★★★★ | 2 | 0 |
| The Suites At Jordan River | 12.5 mi | ★★★★★ | 0 | 0 |
| Kirby Pines Manor | 14.5 mi | ★★★★★ | 0 | 0 |
| The Village At Germantown | 15.3 mi | ★★★★★ | 11 | 1 |
| Signature Healthcare Of Primacy | 16.8 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.