Cycle 1
Health 2025-06-12 · Fire 2025-06-12
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Diberville, MS
Greenbriar Nursing Center
3-star overall rating with 4-star inspections with 4 recent health deficiencies
4347 West Gay Road, Diberville, MS
(228) 392-8484
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
103
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2007-10-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.34
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.52
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
3.87
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.20
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.14
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
4.22
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,177
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9860
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.07
Baseline 24.94% · Performance 20.53% · Measure score 5.07 · Achievement 1.94 · Improvement 5.07
Healthcare-associated infections
1.35
Baseline 9.40% · Performance 8.58% · Measure score 1.35 · Achievement 0 · Improvement 1.35
Total nurse turnover
0
Baseline 64.21% · Performance 70.00% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
5.78
Baseline 4.30 hours · Performance 4.72 hours · Measure score 5.78 · Achievement 5.78 · Improvement 2.34
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.81% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 193 · Observed rate 11.92% · Lower 95% interval 8.51% |
| Discharge to community | 47.47% |
50.57%
3.1 pts worse
|
No Different than the National Rate · Eligible stays 166 · Observed rate 44.58% · Lower 95% interval 40.77% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.35% |
95.27%
2.1 pts better
|
Numerator 110 · Denominator 113 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 113 |
| Discharge self-care score | 64% |
53.69%
10.3 pts better
|
Numerator 48 · Denominator 75 |
| Discharge mobility score | 46.67% |
50.94%
4.3 pts worse
|
Numerator 35 · Denominator 75 |
| Pressure ulcers or injuries, new or worsened | 1.77% |
2.29%
0.5 pts better
|
Numerator 2 · Denominator 113 · Adjusted rate 1.61% |
| Healthcare-associated infections requiring hospitalization | 8.58% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 130 · Observed rate 8.46% · Lower 95% interval 5.39% |
| Staff COVID-19 vaccination coverage | 10.32% |
8.2%
2.1 pts better
|
Numerator 16 · Denominator 155 |
| Staff flu vaccination coverage | 11.16% |
42%
30.8 pts worse
|
Numerator 24 · Denominator 215 |
| Discharge function score | 49.33% |
56.45%
7.1 pts worse
|
Numerator 37 · Denominator 75 |
| Transfer of health information to provider | 93.94% |
95.95%
2 pts worse
|
Numerator 62 · Denominator 66 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 24.53% |
25.2%
0.7 pts worse
|
Numerator 13 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.4
0.8 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
2.9
0.1 pts better
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.5% |
95.7%
2.2 pts worse
|
93.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.1% · Q2 94.0% · Q3 93.2% · Q4 92.1% · 4Q avg 93.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.8% |
97.0%
5.2 pts worse
|
95.5%
3.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.2%
0.3 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.5% · Q3 2.7% · Q4 0.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.5% |
1.6%
8.9 pts worse
|
11.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 6.7% · Q3 8.6% · Q4 14.1% · 4Q avg 10.5% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
6.1%
1 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 7.0% · Q3 6.3% · Q4 1.5% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.2% |
24.4%
2.8 pts worse
|
19.6%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 30.0% · Q3 24.2% · Q4 27.9% · 4Q avg 27.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.9% |
23.4%
5.5 pts better
|
16.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 18.8% · Q3 12.7% · Q4 22.2% · 4Q avg 17.9% · 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 | 20.4% |
22.8%
2.4 pts better
|
16.3%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 40.1% |
20.6%
19.5 pts worse
|
14.9%
25.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 19.6% · Q3 64.1% · Q4 47.8% · 4Q avg 40.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.3% |
1.5%
1.8 pts worse
|
1.0%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 4.2% · Q3 1.2% · Q4 3.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
2.5%
1.4 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.4% |
21.4%
13 pts worse
|
19.8%
14.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 36.7% · Q3 34.2% · Q4 39.5% · 4Q avg 34.4% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
6.9%
3.2 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.6% · Q3 4.3% · Q4 3.9% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 72.7% |
87.9%
15.2 pts worse
|
81.7%
9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 75.0% · Q2 67.2% · Q3 72.4% · Q4 75.9% · 4Q avg 72.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.5% |
15.3%
5.2 pts worse
|
12.0%
8.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.5% · Observed 20.0% · Expected 10.9% · 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 · Q1 0.0% · Q2 0.0% · Q3 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 | 66.7% |
84.6%
17.9 pts worse
|
79.7%
13 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 66.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.8% |
27.9%
10.1 pts better
|
23.9%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.8% · Observed 16.5% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-08 · Fire 2024-02-08
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-11-04 · Fire 2021-11-04
5 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-06-12
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-06-12
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-06-12
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-07-09
D · Potential for more than minimal harm
2024-11-12
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-02-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-28
D · Potential for more than minimal harm
2024-02-08
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-03-28
D · Potential for more than minimal harm
2024-02-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-28
D · Potential for more than minimal harm
2021-11-04
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 2021-12-26
D · Potential for more than minimal harm
2021-11-04
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 2021-12-26
D · Potential for more than minimal harm
2021-11-04
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 2021-12-26
D · Potential for more than minimal harm
2021-11-04
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-12-26
D · Potential for more than minimal harm
2021-11-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-26
Penalties and ownership
What sits behind the stars
Ownership
Cain, Avonna
5% Or Greater Direct Ownership Interest · Individual
Ashley, Heather
Operational/Managerial Control · Individual
Cain, Avonna
Corporate Officer · Individual
Johns, Stephen
Operational/Managerial Control · Individual
Nearby options
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#2
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#3
Sunplex Sub-Acute Center
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1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $123,994 in total fines with 15 recent health deficiencies
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