Clean, well-maintained and updated facility spaces
Large therapy gym and ADL training suite
Active resident activities and social programming
Responsive admissions and family-facing administration
Supportive dietary leadership and hot-meal service
Successful short-term rehabilitation outcomes
Welcoming unit-level staff and positive social environment
Cons
Inconsistent staffing levels and weekend coverage
Variable responsiveness to call lights and care requests
Gaps in clinical monitoring and timely escalation
Inconsistent communication with families and care teams
Hygiene and odor concerns in selected areas
Unreliable incontinence-care and bathing schedules
Medication administration and documentation issues
Weak personal-property and belongings management
Inconsistent meal quality and menu rotation
Shift-to-shift handoff and leadership oversight gaps
Summary of reviews
Great Oaks Rehabilitation and Healthcare Center elicits strongly mixed impressions. Many families and patients describe attentive, compassionate direct-care staff, a robust therapy department, and pleasant facility spaces that support rehabilitation. Positive comments concentrate on individual caregivers, the therapy gym and ADL suite, wound-care capabilities, and an admissions team that can provide a smooth transition. Multiple accounts recount successful short-term rehab outcomes and engaged dietary leadership that delivers hot meals.
Counterbalancing those positives, a substantial number of accounts raise operational concerns that affect safety and dignity. Common themes include inconsistent staffing (notably reduced weekend coverage), variable responsiveness to call lights and care requests, and documented lapses in clinical monitoring and escalation that in some cases required emergency hospital transfer. Families also describe gaps in communication and inconsistent reporting of status changes, which complicate care coordination and discharge planning.
Care-process issues appear in several domains. Hygiene and odor concerns in particular common areas and resident rooms are noted alongside inconsistent incontinence-care and bathing schedules. Reviews also raise concerns about medication administration practices and documentation, delayed wound or pressure-injury attention, and uneven follow-through on physician orders. Property-management lapses such as lost or delayed return of personal items were reported, which contributes to family frustration.
The dining and activity programs receive mixed feedback: some reviewers praise hot, satisfying meals and an active events calendar, while others describe repetitive menu items and inconsistent meal quality. The facility environment is frequently described as clean and well-maintained, with modern amenities and a welcoming atmosphere, though a subset of accounts describe localized sanitation and odor problems that require attention.
Management and leadership impressions are polarizing. Several families highlight visible, engaged administrators and responsive social work and therapy teams; others describe broken promises, appointment changes without consent, inconsistent shift leadership, and at least one allegation of privacy breach. These divergent views create a pattern of highly variable experience depending on unit, shift, and individual staff assignment.
Taken together, the pattern suggests a facility with clear strengths in therapy, many dedicated caregivers, and generally attractive physical resources, but with recurring operational weaknesses that affect continuity of care and family confidence. Prospective residents and families should weigh the strong rehabilitation services and positive staff relationships against documented variability in staffing, communication, hygiene protocols, and clinical escalation. When considering placement, ask specific questions about weekend staffing ratios, handoff procedures, medication administration practices, incontinence and bathing schedules, and how the facility communicates clinical changes to families. If possible, meet the therapy team and unit nursing leadership and review the most recent state survey and corrective-action history to understand how ongoing issues are being addressed.
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Medicare Ratings
1·/ 5
Overall
Health Inspection
Staffing
Quality Measures
Ratings from the U.S. Centers for Medicare & Medicaid Services (Care Compare). View on Medicare.gov
Location
Great Oaks Rehabilitation and Healthcare Center is located at 111 Chase St, Byhalia, MS, 38611.
About Great Oaks Rehabilitation and Healthcare Center
Great Oaks Rehabilitation and Healthcare Center, managed by Francis Kirley since July 2018, is a 60-bed for-profit facility affiliated with Nexion Health. The center keeps an average of 49 residents each day. Great Oaks focuses on rehabilitation, skilled nursing, and long-term care, aiming to give each resident a comfortable place that feels like home. Staffed by interdisciplinary care professionals, the facility offers care 24 hours a day, including services from licensed nurses on every shift and physician oversight. Caregivers average 4.30 nurse hours per resident per day, and staffing levels follow care requirements.
Daily, residents have access to specialized rehabilitation services, including occupational and physical therapy from trained therapists. There's wound care, telemedicine, and healthcare services, as well as programs named after Great Oaks Rehabilitation and Healthcare Center. The facility says it wants to protect residents from abuse, neglect, and exploitation, and infection-control procedures are in place, though the center has had deficiencies in infection prevention and control.
Residents can join amenities and activities, which are designed to support comfort and well-being throughout both short-term recovery and long-term stays. Admission is available at any time, day or night. The center seeks to give individualized care for every resident, whether they need skilled nursing, wound care, rehabilitation, or long-term support. The facility's mascot, Oakley the goose, is their official good luck charm. Great Oaks works to provide a safe, caring environment, using a team with plenty of experience aiming to help residents have the highest quality of life possible during their healing experience.
People often ask...
Great Oaks Rehabilitation and Healthcare Center offers assisted living, memory care, and skilled nursing.
There are 19 photos of Great Oaks Rehabilitation and Healthcare Center on Mirador.
The full address for this community is 111 Chase St, Byhalia, MS 38611.
No, Great Oaks Rehabilitation and Healthcare Center does not offer respite care.
Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.
Safety & Compliance
In Mississippi, the State Department of Health licenses care facilities and publishes the survey, complaint, and infection-control reports from its inspections.
License number
nh-255311
Facility type
Nursing Home
Special certification
Medicaid/Medicare – Dually certified
Inspection Reports
80
Reports
48
Citations
39
Complaints
6
Years
01 Aug 2026Complaint
01 Aug 2026Complaint
Investigated the complaint and found no deficiencies.
01 Aug 2026Complaint
01 Aug 2026Complaint
Found no deficiencies after a complaint investigation conducted on 2026-08-19. Determined to be in compliance with Medicare and Medicaid participation requirements.
01 Jun 2026Revisit
01 Jun 2026Revisit
Found no deficiencies.
01 Jun 2026Revisit
01 Jun 2026Revisit
Determined corrective measures were in place to address a deficient practice. Recommended returning to compliance.
01 May 2026Inspection
01 May 2026Inspection
Found that MDS assessments were not completed and transmitted within CMS timeframes for Resident #30.
§483.20(f)Automated data processing requirement
01 May 2026Inspection
01 May 2026Inspection
Found no deficiencies during the annual recertification survey and complaint investigation; determined compliance with minimum standards and licensure requirements.
01 May 2026Inspection
01 May 2026Inspection
Found no deficiencies. Emergency preparedness requirements were met during the survey.
01 Mar 2026Complaint
01 Mar 2026Complaint
Investigated a complaint and found no deficiencies cited.
01 Mar 2026Complaint
01 Mar 2026Complaint
Found no deficiencies. The investigation concluded compliance with applicable standards.
01 Dec 2025Revisit
01 Dec 2025Revisit
Determined no deficiencies and placed back in compliance after review of information provided.
01 Dec 2025Revisit
01 Dec 2025Revisit
Determined that compliance was restored as of 12/26/2025.
01 Nov 2025Complaint
01 Nov 2025Complaint
Identified a deficiency in medical records management due to an unentered therapy order, leading to an incomplete resident medical record.
45.25.1Medical Records Management
01 Nov 2025Complaint
01 Nov 2025Complaint
Investigated a complaint and found violations in notification of changes after hospital readmission, reporting alleged violations, investigating injuries, and maintaining medical records.
483.10(g)(14)Notify of Changes.
483.12(b)(5)(i)(A)(B)(c)(1)(4); 483.12(c)Reporting of Alleged Violations.
483.70(h); 483.20(f)(5)Resident Records - Identifiable Information
01 Aug 2025Revisit
01 Aug 2025Revisit
Found no deficiencies cited after reviewing emergency preparedness measures. The review indicated compliance with applicable requirements.
01 Aug 2025Revisit
01 Aug 2025Revisit
Determined compliance with the applicable minimum standards and recommended placing back in compliance.
01 Aug 2025Revisit
01 Aug 2025Revisit
Concluded that the facility was back in compliance after a desk review. The agency recommended maintaining compliance.
01 Jul 2025Complaint
01 Jul 2025Complaint
Investigated a complaint and found no deficiencies cited in this visit; however, deficiencies from the 6/25/25 survey left the provider out of compliance.
01 Jul 2025Complaint
01 Jul 2025Complaint
Determined no deficiencies on this survey, but noted deficiencies from the 6/25/25 survey left it out of compliance.
01 Jun 2025Inspection
01 Jun 2025Inspection
Identified multiple deficiencies including absence of informed consent discussion for psychotropic meds, inaccessible call lights, a damaged wheelchair, inaccurate discharge coding, hazardous materials in a resident's room, and an indwelling catheter without orders.
CFR 483.10(c)(1)(4)(5)Right to be informed/participate in treatment decisions
CFR 483.10(e)(3)Reasonable accommodations/needs and preferences
Investigated a set of deficiencies: lack of informed consent discussions for psychotropic medications, presence of hazardous materials left in resident rooms, and inappropriate management of a Foley catheter on admission.
45.17.2 Residents' RightsResidents' Rights
45.21.8 AccidentsAccidents
45.21.11 Special needsSpecial needs
01 Jun 2025Inspection
01 Jun 2025Inspection
Found that fire alarm system inspection documentation for 2025 was missing, and the last inspection occurred in 2024.
NFPA 72 Table 14.3.1; NFPA 72 section 14.4.5.3.2Fire alarm system inspection and testing documentation
01 Jun 2025Inspection
01 Jun 2025Inspection
Found deficiencies in fire alarm system testing/maintenance and in smoke barrier door operation.
NFPA 101 9.6.1.3; 9.6.1.5; NFPA 70; NFPA 72Fire Alarm System - Testing and Maintenance
NFPA 101 19.3.7.6; 19.3.7.8; 19.3.7.9Subdivision of Building Spaces - Smoke Barrier Doors
01 Jun 2025Revisit
01 Jun 2025Revisit
Verified compliance after corrective actions were implemented and sustained; recommended returning to compliance as of 06/11/2025.
01 Jun 2025Revisit
01 Jun 2025Revisit
Concluded that compliance was restored.
01 May 2025Complaint
01 May 2025Complaint
Investigated found that bed rails were removed without a safety assessment, resulting in a resident rolling out of bed and sustaining a head laceration requiring emergency care.
42 CFR 483.25(d)Free of Accident Hazards/Supervision/Devices
01 May 2025Complaint
01 May 2025Complaint
Investigated complaints about resident safety and supervision; found that bed rails were removed without safety assessment, resulting in a resident fall with head injury and ongoing safety concerns.
45.21.8Accidents
01 Mar 2025Complaint
01 Mar 2025Complaint
Found no deficiencies. The investigation determined compliance with applicable standards.
01 Mar 2025Complaint
01 Mar 2025Complaint
Determined no deficiencies were cited after a complaint investigation.
01 Nov 2024Revisit
01 Nov 2024Revisit
Determined that no deficiencies were found and that compliance was restored after a desk review.
01 Nov 2024Revisit
01 Nov 2024Revisit
Verified the prior deficiency was addressed and compliance was restored.
01 Oct 2024Complaint
01 Oct 2024Complaint
Investigated misappropriation of a resident's funds by a CNA; found a violation of residents' rights due to misuse of a resident's debit card and funds.
45.17.2Residents' Rights
01 Oct 2024Complaint
01 Oct 2024Complaint
Investigated complaints found misappropriation of a resident's funds and insufficient staffing, including delays in care. A staff member used a resident's debit card and funds, and staffing shortages affected multiple residents.
CFR 483.12Free from Misappropriation/Exploitation
CFR 483.35Sufficient Nursing Staff
01 Jun 2024Revisit
01 Jun 2024Revisit
Found no deficiencies.
01 Jun 2024Revisit
01 Jun 2024Revisit
Determined corrective actions were in place and recommended returning to compliance.
01 May 2024Complaint
01 May 2024Complaint
Identified failure to notify the resident representative of a medication change for one resident when Hydrocortisone was discontinued due to a potential interaction with Desmopressin Acetate.
483.10(g)(14)Notification of Changes
01 May 2024Complaint
01 May 2024Complaint
Investigated a complaint and found no deficiencies.
01 May 2024Revisit
01 May 2024Revisit
Determined that compliance was restored after review of information and actions taken.
01 Feb 2024Revisit
01 Feb 2024Revisit
Recommended placement back into compliance after a desk review confirmed corrective actions were in place.
01 Feb 2024Revisit
01 Feb 2024Revisit
Concluded that the facility was in compliance with the minimum standards and recommended placing it back in compliance.
01 Feb 2024Revisit
01 Feb 2024Revisit
Determined compliance after a desk review and recommended reinstating compliance.
01 Feb 2024Revisit
01 Feb 2024Revisit
Concluded the provider was placed back in compliance after a desk review.
01 Jan 2024Complaint
01 Jan 2024Complaint
Found that timely incontinent care was not provided for a resident who had a bowel movement, resulting in a delay of about 90 minutes before care was delivered.
45.21.2Activities of daily living
01 Jan 2024Inspection
01 Jan 2024Inspection
Identified multiple deficiencies across resident rights, care planning, medication management, ADL care, MDS timing, drug storage, and infection control.
§483.10(c)(6)The right to request/refuse/discontinue treatment; formulate advance directives
§483.21(b)(1)-(3)Develop/Implement Comprehensive Care Plan
§483.21(b)(3)(i)Services Provided Meet Professional Standards
§483.24(a)(2)ADL Care Provided for Dependent Residents
§§483.45(g)-(h)Label/Store Drugs and Biologicals; Storage
§483.80(a)(1)-(f)Infection Prevention & Control
01 Jan 2024Inspection
01 Jan 2024Inspection
The regulator identified deficiencies in daily living support, medication security, and infection control, including delays in incontinent care, unlocked medication carts with medications exposed, and improper hand hygiene and equipment storage during treatments.
45.21.2 Activities of daily livingActivities of daily living
45.24.2 Policies and proceduresPolicies and procedures
48.58.1 Infection ControlInfection Control
01 Jan 2024Complaint
01 Jan 2024Complaint
Identified failures to implement an ADL care plan and delays in incontinent care for a resident, risking hygiene issues and possible skin breakdown.
CFR 483.21(b)(1)(3)Comprehensive Care Plans
CFR 483.24(a)(2)ADL Care Provided for Dependent Residents
01 Jan 2024Inspection
01 Jan 2024Inspection
Found no deficiencies identified during the visit.
01 Jan 2024Inspection
01 Jan 2024Inspection
Found no deficiencies. Emergency preparedness requirements were met.
01 Sept 2023Complaint
01 Sept 2023Complaint
Found no deficiencies.
01 Sept 2023Complaint
01 Sept 2023Complaint
Investigated a complaint and found no deficiencies.
01 Mar 2023Complaint
01 Mar 2023Complaint
Investigated a complaint and concluded no deficiencies were cited.
01 Mar 2023Complaint
01 Mar 2023Complaint
Found no deficiencies. The survey determined compliance with minimal standards of operation for institutions for the aged or infirm.
01 Jan 2023Revisit
01 Jan 2023Revisit
Concluded corrective actions were in place and recommended that the provider be placed back in compliance effective 12/29/22.
01 Jan 2023Revisit
01 Jan 2023Revisit
Determined compliance with minimum standards and recommended returning to compliance.
01 Jan 2023Revisit
01 Jan 2023Revisit
Determined back in compliance after reviewing information from the annual survey. Recommended placing back in compliance effective 12/29/22.
01 Jan 2023Revisit
01 Jan 2023Revisit
Placed back in compliance after a desk review; no deficiencies cited.
01 Dec 2022Complaint
01 Dec 2022Complaint
Investigated a complaint alleging resident neglect related to pressure ulcers; found no substantiation for that allegation and no deficiencies cited in this action, but ongoing noncompliance remains from deficiencies cited in a prior survey.
01 Dec 2022Complaint
01 Dec 2022Complaint
Investigated a complaint alleging neglect related to pressure ulcers; found no deficiencies cited in this visit, but noted ongoing noncompliance from a prior survey.
01 Nov 2022Inspection
01 Nov 2022Inspection
Investigated a complaint and found deficiencies in data encoding/transmission, oxygen-use signage, and infection control practices, indicating risks to residents.
§483.25(i)Respiratory/Tracheostomy Care and Suctioning
§483.80(a)Infection Prevention & Control
01 Nov 2022Inspection
01 Nov 2022Inspection
Investigated a transfer-related accident hazard due to improper use of a mechanical lift and found missing oxygen-use room signage for residents on oxygen.
45.21.8Accidents
45.21.11Special needs
01 Nov 2022Complaint
01 Nov 2022Complaint
Investigated a reported abuse/neglect allegation and a lift-related accident; found failures to report timely and to ensure safe transfer during a lift, potentially affecting a resident.
483.12(c)Reporting of Alleged Violations
483.25(d)Free of Accident Hazards/Supervision/Devices
01 Nov 2022Inspection
01 Nov 2022Inspection
Found no deficiencies in emergency preparedness during the survey.
01 Nov 2022Inspection
01 Nov 2022Inspection
Found no deficiencies.
01 Jun 2021Complaint
01 Jun 2021Complaint
Investigated a complaint alleging quality of care and pressure ulcers. Concluded there was no evidence of noncompliance with participation requirements.
01 Jun 2021Complaint
01 Jun 2021Complaint
Investigated a complaint about quality of care and pressure ulcers and found no deficiencies.
01 Apr 2021Infection Control
01 Apr 2021Infection Control
Found no deficiencies related to infection control during the COVID-19 focused survey.
01 Apr 2021Infection Control
01 Apr 2021Infection Control
Concluded no deficiencies were found in the COVID-19 focused emergency preparedness review and confirmed compliance with applicable requirements.
01 Nov 2020Infection Control
01 Nov 2020Infection Control
Found compliance with infection control requirements during a focused COVID-19 survey.
01 Nov 2020Infection Control
01 Nov 2020Infection Control
Determined compliance with COVID-19 focused emergency preparedness requirements during a survey.
01 Nov 2020Infection Control
01 Nov 2020Infection Control
Found no deficiencies in infection control practices. Compliance with infection control regulations was verified.
01 Nov 2020Infection Control
01 Nov 2020Infection Control
Confirmed compliance with emergency preparedness requirements during a Covid-19 focused review; no deficiencies were cited.
01 Oct 2020Infection Control
01 Oct 2020Infection Control
Investigated a reported verbal abuse incident and found a deficiency for failing to protect a resident from verbal abuse by an employee.
42 CFR §483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
01 Oct 2020Complaint
01 Oct 2020Complaint
Investigated a verbal abuse incident toward a resident and cited a violation of abuse prevention rules.
42 CFR §483.12Freedom from Abuse, Neglect, and Exploitation
01 Oct 2020Infection Control
01 Oct 2020Infection Control
Concluded that infection control requirements were met during a focused survey.
01 Jul 2020Infection Control
01 Jul 2020Infection Control
Found incomplete COVID-19 reporting to NHSN during a seven-day period.
§483.80(g)COVID-19 reporting
01 Jul 2020Infection Control
01 Jul 2020Infection Control
Found no deficiencies. Confirmed compliance with emergency preparedness requirements.
01 Jul 2020Infection Control
01 Jul 2020Infection Control
Determined no deficiencies were found in infection control practices related to Covid-19.
01 Jun 2020Infection Control
01 Jun 2020Infection Control
Found no deficiencies related to infection control; compliance with covid-19 infection control practices was confirmed.
01 Jun 2020Infection Control
01 Jun 2020Infection Control
Found no deficiencies related to infection control practices during a COVID-19 focused review.
01 Jan 2020Inspection
01 Jan 2020Inspection
Found a deficiency in maintaining exit egress; the courtyard exit lacked an all-weather surface leading to the public way.
42 CFR 483.70(a)Means of Egress - General
01 Jan 2020Inspection
01 Jan 2020Inspection
Found no deficiencies and determined compliance with Medicare/Medicaid participation requirements.
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