Great Oaks Rehabilitation and Healthcare Center

Name: Great Oaks Rehabilitation and Healthcare Center
Address: 111 CHASE STREET, Byhalia, MS, 38611, US
Telephone: 6628383670

111 Chase Street, Byhalia, MS 38611 · Marshall County · 60 certified beds · avg 47 residents/day · certified since Feb 24, 2005

Part of chain: NEXION HEALTH (51 facilities, chain avg rating 2.2★)

3/5

Health inspection rating (on-site)

Serious findings on record

$8,788

Fines, last 3 years

4.80

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 2/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · May 22, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jun 11, 2025 (Deficient, Provider has date of correction)

All citations in the current public record (22)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
May 20, 2026	D · Potential for harm, one-off	The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require.
Nov 6, 2025	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Nov 6, 2025	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Nov 6, 2025	D · Potential for harm, one-off	The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Nov 6, 2025	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Jun 25, 2025	D · Potential for harm, one-off	The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Jun 25, 2025	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Jun 25, 2025	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Jun 25, 2025	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jun 25, 2025	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jun 25, 2025	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
May 22, 2025	▲ G · Actual harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Oct 1, 2024	E · Potential for harm, repeated	The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Oct 1, 2024	D · Potential for harm, one-off	The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint
May 15, 2024	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Jan 4, 2024	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jan 4, 2024	D · Potential for harm, one-off	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Jan 4, 2024	D · Potential for harm, one-off	The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require.
Jan 4, 2024	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Jan 4, 2024	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Jan 4, 2024	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Jan 4, 2024	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (6 → 1).

Year	Citations	Serious (G–L)	Worst severity that year
2024	10	0	E
2025	11	1	G ▲
2026	1	0	D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $8,788.

Date	Type	Amount / length
May 22, 2025	Fine	$8,788

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Mississippi avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	4.80	4.88	3.95	top 43% in Mississippi; top 17% in the U.S.
Registered Nurse hours	0.44	0.74	0.69	bottom 13% in Mississippi; bottom 29% in the U.S.
Weekend total nurse staffing	4.20	4.09	3.50	top 31% in Mississippi; top 18% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.37	0.38	0.48	top 36% in Mississippi; bottom 46% in the U.S.
Total nursing staff turnover (%)	64.3	45.7	45.8	bottom 7% in Mississippi; bottom 11% in the U.S.
RN turnover (%)	57.1	38.4	42.9	bottom 20% in Mississippi; bottom 26% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.32, RN 0.40, weekend 3.78. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 1/5 · long-stay residents: 1/5 · short-stay residents: 1/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Bolt, Bretton	Individual	5% or Greater Indirect Ownership Interest	—	03/29/2018
Kirley, Francis	Individual	5% or Greater Indirect Ownership Interest	—	03/29/2018
Nexion Health Leasing, INC.	Organization	5% or Greater Indirect Ownership Interest	—	03/29/2018
Nexion Health of Ohi INC	Organization	5% or Greater Direct Ownership Interest	100%	03/29/2018
Nexion Health, INC.	Organization	5% or Greater Indirect Ownership Interest	—	03/29/2018
Kirley, Francis	Individual	Corporate Director	NOT APPLICABLE	03/29/2018
Kirley, Francis	Individual	Corporate Officer	NOT APPLICABLE	03/29/2018
Kirley, Francis	Individual	Operational/Managerial Control	NOT APPLICABLE	07/01/2018
Lee, Brian	Individual	Corporate Director	NOT APPLICABLE	03/29/2018
Lee, Brian	Individual	Corporate Officer	NOT APPLICABLE	03/29/2018
Oswald, John	Individual	Corporate Director	NOT APPLICABLE	03/24/2022
Pierce, Daniel	Individual	Corporate Officer	NOT APPLICABLE	03/16/2021
Reid, John	Individual	Corporate Director	NOT APPLICABLE	12/18/2018
Riner, Meera	Individual	Corporate Director	NOT APPLICABLE	03/29/2018
Riner, Meera	Individual	Corporate Officer	NOT APPLICABLE	03/29/2018

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"How do you make sure resident assessments are completed and submitted to the state on time?"
"If my family member falls or their condition changes, exactly when and how will I be notified?"
"When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
"If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
"How do you keep residents' medical records accurate, complete, and secure?"
"How do you explain health changes and treatment options to residents and their families?"
"Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection
Collierville Nursing and Rehabilitation, LLC	12.4 mi	Collierville, TN	★★☆☆☆	3/5
The Suites at Jordan River	12.4 mi	Collierville, TN	★★★☆☆	4/5
Kirby Pines Manor	14.5 mi	Memphis, TN	★★★★★	5/5
The Village at Germantown	15.3 mi	Germantown, TN	★★☆☆☆	1/5
Signature Healthcare of Primacy	16.9 mi	Memphis, TN	★★★★★	4/5
Quince Nursing and Rehabilitation Center	16.9 mi	Memphis, TN	★★☆☆☆	1/5
Waters of Memphis a Rehabilitation & Nursing Ctr	16.9 mi	Memphis, TN	★☆☆☆☆	2/5
Delta Blues Health & Rehabilitation	17.6 mi	Memphis, TN	★★☆☆☆	2/5
Desoto Healthcare Center	17.7 mi	Southaven, MS	★★★☆☆	3/5
Cordova Wellness and Rehabilitation Center	18.5 mi	Cordova, TN	★★★☆☆	3/5
Memphis Jewish Home	18.5 mi	Cordova, TN	★★★★☆	4/5
Applingwood Post Acute	18.5 mi	Cordova, TN	★★☆☆☆	2/5

Compare this facility with the 3 closest →

All facilities in Byhalia →

Facility data as of CMS processing date 2026-08-01. CCN 255311.

The Care File

Visit checklist — Great Oaks Rehabilitation and Healthcare Center

111 Chase Street, Byhalia, MS 38611 · 6628383670

Health inspection rating 3/5 · CMS overall 2/5· Fines (3y): $8,788

Most serious findings on record:

▲ May 22, 2025 (F-0689, Actual harm, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "How do you make sure resident assessments are completed and submitted to the state on time?"
☐ "If my family member falls or their condition changes, exactly when and how will I be notified?"
☐ "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
☐ "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
☐ "How do you keep residents' medical records accurate, complete, and secure?"
☐ "How do you explain health changes and treatment options to residents and their families?"
☐ "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 255311 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)