Cycle 1
Health 2024-08-15 · Fire 2024-08-15
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Florence, MS
Briar Hill Rest Home
2-star overall rating with 2-star inspections with abuse icon flag with $8,788 in total fines with 6 recent health deficiencies
1201 Gunter Road, Florence, MS
(601) 939-6371
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Briar Hill Management
Operator or chain grouping
Approved since
2003-09-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 4 staffing / 2 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
0.64
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.23
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
4.04
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.87
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.25
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
4.48
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,157
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.85
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.43
Baseline 19.80% · Performance 20.77% · Measure score 1.43 · Achievement 1.43 · Improvement 0
Healthcare-associated infections
0
Baseline 8.29% · Performance 8.19% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.63
Baseline 70.91% · Performance 61.11% · Measure score 1.63 · Achievement 0.63 · Improvement 1.63
Adjusted total nurse staffing
4.09
Baseline 4.19 hours · Performance 4.24 hours · Measure score 4.09 · Achievement 4.09 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.95% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 13.73% · Lower 95% interval 7.55% |
| Discharge to community | 49.66% |
50.57%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 40% · Lower 95% interval 37.63% |
| Medicare spending per beneficiary | 1.38 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 48 · Denominator 48 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 48 |
| Discharge self-care score | 33.33% |
53.69%
20.4 pts worse
|
Numerator 8 · Denominator 24 |
| Discharge mobility score | 37.5% |
50.94%
13.4 pts worse
|
Numerator 9 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 2.08% |
2.29%
0.2 pts better
|
Numerator 1 · Denominator 48 · Adjusted rate 1.72% |
| Healthcare-associated infections requiring hospitalization | 8.19% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 13.51% · Lower 95% interval 4.28% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 77 |
| Staff flu vaccination coverage | 12.5% |
42%
29.5 pts worse
|
Numerator 10 · Denominator 80 |
| Discharge function score | 41.67% |
56.45%
14.8 pts worse
|
Numerator 10 · Denominator 24 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 30 · Denominator 30 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 10% |
25.2%
15.2 pts worse
|
Numerator 3 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 5.5 |
2.4
3.1 pts worse
|
1.9
3.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.5 · Observed 4.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
2.9
0.2 pts better
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.0%
3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.2%
0.5 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 2.1% · Q4 4.9% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.1% |
1.6%
1.5 pts worse
|
11.4%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · Q3 2.3% · Q4 5.4% · 4Q avg 3.1% |
| Percentage of long-stay residents who lose too much weight | 10.0% |
6.1%
3.9 pts worse
|
5.4%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 10.5% · Q3 0.0% · Q4 6.2% · 4Q avg 10.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.3% |
24.4%
10.1 pts better
|
19.6%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 14.6% · Q3 20.0% · Q4 11.1% · 4Q avg 14.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.7% |
23.4%
4.3 pts worse
|
16.7%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 27.3% · Q3 29.4% · Q4 33.3% · 4Q avg 27.7% · 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 | 16.2% |
22.8%
6.6 pts better
|
16.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.7% |
20.6%
6.9 pts better
|
14.9%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 7.9% · Q3 15.8% · Q4 14.3% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.3% |
1.5%
0.8 pts worse
|
1.0%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.3% · Q3 2.5% · Q4 2.6% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
2.5%
0.7 pts better
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 2.3% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.8% |
21.4%
3.4 pts worse
|
19.8%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 26.8% · Q3 22.0% · Q4 31.8% · 4Q avg 24.8% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
6.9%
0.7 pts better
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 5.2% · Q3 8.4% · Q4 9.7% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
87.9%
12.1 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.8% |
15.3%
8.5 pts worse
|
12.0%
11.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 23.7% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.6%
2.6 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.6% |
84.6%
4 pts worse
|
79.7%
0.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 37.0% |
27.9%
9.1 pts worse
|
23.9%
13.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 37.0% · Observed 35.6% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-19 · Fire 2023-01-19
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-08-29 · Fire 2019-08-29
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
G · Actual harm
2025-04-09
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 2025-04-30
E · Potential for more than minimal harm
2024-08-15
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 2024-09-25
D · Potential for more than minimal harm
2024-08-15
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-09-25
D · Potential for more than minimal harm
2024-08-15
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 2024-09-25
D · Potential for more than minimal harm
2024-08-15
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 2024-09-25
D · Potential for more than minimal harm
2024-08-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-09-25
D · Potential for more than minimal harm
2024-08-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-09-25
D · Potential for more than minimal harm
2024-08-15
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-09-25
D · Potential for more than minimal harm
2023-01-19
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-02-15
E · Potential for more than minimal harm
2019-08-29
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-10-01
D · Potential for more than minimal harm
2019-08-29
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 2019-10-01
D · Potential for more than minimal harm
2019-08-29
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2019-10-01
D · Potential for more than minimal harm
2019-08-29
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2019-10-01
D · Potential for more than minimal harm
2019-08-29
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-10-01
D · Potential for more than minimal harm
2019-08-29
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2019-10-01
Penalties and ownership
What sits behind the stars
$8,788
2025-04-09
Fine
Fine · fine $8,788
Fine
Ownership
Rotolo, David
5% Or Greater Direct Ownership Interest · Individual
Rotolo, Robert
5% Or Greater Direct Ownership Interest · Individual
Philippe, Lynn
5% Or Greater Direct Ownership Interest · Individual
Briar Hill Management, LLC
Operational/Managerial Control · Organization
Burlison, Sandy
Operational/Managerial Control · Individual
Burns, Sharon
Operational/Managerial Control · Individual
Davis, Tracy
Operational/Managerial Control · Individual
Freeman, James
Operational/Managerial Control · Individual
Green, Donna
Operational/Managerial Control · Individual
King, Curtis
Operational/Managerial Control · Individual
Muha, Ashley
Operational/Managerial Control · Individual
Rotolo, David
Operational/Managerial Control · Individual
Rotolo, Robert
Operational/Managerial Control · Individual
White, Deborah
Operational/Managerial Control · Individual
Whitlow, Carrie
Operational/Managerial Control · Individual
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#3
Jnh-Madison Inn
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