Cycle 1
Health 2025-09-18 · Fire 2025-09-18
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Florence, AL
Mitchell-Hollingsworth Nursing & Rehabilitation
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
805 Flagg Circle, Florence, AL
(256) 740-5400
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
222
Certified beds
Average residents
193
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Preston Health Services
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 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
0.77
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.67
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.89
CMS adjusted RN staffing hours
Adjusted total hours
4.24
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,436
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9824
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.13% · Performance 25.05% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.23% · Performance 8.69% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.91
Baseline 40.99% · Performance 39.53% · Measure score 5.91 · Achievement 5.91 · Improvement 0.40
Adjusted total nurse staffing
2.25
Baseline 3.75 hours · Performance 3.72 hours · Measure score 2.25 · Achievement 2.25 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.25% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 490 · Observed rate 11.02% · Lower 95% interval 9.16% |
| Discharge to community | 57.4% |
50.57%
6.8 pts better
|
Better than the National Rate · Eligible stays 491 · Observed rate 51.73% · Lower 95% interval 53.09% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.39% |
95.27%
4.1 pts better
|
Numerator 328 · Denominator 330 |
| Falls with major injury | 0.91% |
0.77%
0.1 pts worse
|
Numerator 3 · Denominator 330 |
| Discharge self-care score | 44.78% |
53.69%
8.9 pts worse
|
Numerator 90 · Denominator 201 |
| Discharge mobility score | 41.79% |
50.94%
9.1 pts worse
|
Numerator 84 · Denominator 201 |
| Pressure ulcers or injuries, new or worsened | 5.49% |
2.29%
3.2 pts worse
|
Numerator 18 · Denominator 328 · Adjusted rate 4.39% |
| Healthcare-associated infections requiring hospitalization | 8.69% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 281 · Observed rate 8.9% · Lower 95% interval 6.23% |
| Staff COVID-19 vaccination coverage | 0.34% |
8.2%
7.9 pts worse
|
Numerator 1 · Denominator 295 |
| Staff flu vaccination coverage | 26.69% |
42%
15.3 pts worse
|
Numerator 75 · Denominator 281 |
| Discharge function score | 42.29% |
56.45%
14.2 pts worse
|
Numerator 85 · Denominator 201 |
| Transfer of health information to provider | 93.2% |
95.95%
2.8 pts worse
|
Numerator 96 · Denominator 103 |
| Transfer of health information to patient | 97.06% |
96.28%
0.8 pts better
|
Numerator 165 · Denominator 170 |
| Resident COVID-19 vaccinations up to date | 4.49% |
25.2%
20.7 pts worse
|
Numerator 8 · Denominator 178 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.0
0.3 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.8
1.1 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.7% |
91.3%
2.4 pts better
|
93.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 94.0% · Q3 94.3% · Q4 86.3% · 4Q avg 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.4% |
94.8%
4.6 pts better
|
95.5%
3.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.4%
0.7 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.7% · Q3 2.1% · Q4 2.7% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
1.3%
0.9 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
5.3%
1 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 1.9% · Q3 4.8% · Q4 5.7% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.2% |
24.9%
12.3 pts worse
|
19.6%
17.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.8% · Q2 34.0% · Q3 38.1% · Q4 41.0% · 4Q avg 37.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.8% |
22.8%
4 pts better
|
16.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 16.4% · Q3 14.9% · Q4 19.7% · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.6%
0.6 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 | 21.9% |
14.8%
7.1 pts worse
|
16.3%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 41.5% · Q3 14.7% · Q4 8.0% · 4Q avg 21.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.8% |
13.4%
0.4 pts worse
|
14.9%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 15.6% · Q3 18.3% · Q4 4.0% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.3%
About the same
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.3% · Q3 1.2% · Q4 1.6% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
2.6%
0.7 pts better
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 0.0% · Q3 2.1% · Q4 1.4% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.4% |
13.5%
0.9 pts worse
|
19.8%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 13.4% · Q3 14.5% · Q4 14.8% · 4Q avg 14.4% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
5.7%
1.2 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.0% · Q3 4.3% · Q4 6.2% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
84.3%
14.5 pts better
|
81.7%
17.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.7% · Q2 98.4% · Q3 98.6% · Q4 98.5% · 4Q avg 98.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.5% |
11.5%
3 pts better
|
12.0%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.5% · Observed 8.9% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
2.1%
0.7 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.0% · Q3 3.4% · Q4 4.2% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.4% |
80.3%
10.1 pts better
|
79.7%
10.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.0% |
24.5%
2.5 pts worse
|
23.9%
3.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.0% · Observed 29.4% · Expected 25.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-09-05 · Fire 2019-09-05
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-08-02 · Fire 2018-08-02
4 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-11-12
E · Potential for more than minimal harm
2019-09-05
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2019-10-08
D · Potential for more than minimal harm
2019-09-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-10-08
D · Potential for more than minimal harm
2019-09-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-10-08
E · Potential for more than minimal harm
2018-08-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2018-08-08
D · Potential for more than minimal harm
2018-08-02
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2018-08-08
D · Potential for more than minimal harm
2018-08-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-08-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-18
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 2025-11-05
D · Potential for more than minimal harm
2025-09-18
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-11-05
D · Potential for more than minimal harm
2025-09-18
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-11-05
D · Potential for more than minimal harm
2025-09-18
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 2025-11-05
D · Potential for more than minimal harm
2025-09-18
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-11-05
D · Potential for more than minimal harm
2025-09-18
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-11-05
D · Potential for more than minimal harm
2019-09-05
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2019-10-08
F · Potential for more than minimal harm
2018-08-02
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 2018-09-04
D · Potential for more than minimal harm
2018-08-02
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2018-09-04
D · Potential for more than minimal harm
2018-08-02
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2018-09-04
D · Potential for more than minimal harm
2018-08-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-09-04
Penalties and ownership
What sits behind the stars
Ownership
Walker, James
5% Or Greater Direct Ownership Interest · Individual
Rose, Kenneth
Contracted Managing Employee · Individual
Walker, James
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
El Reposo Nursing Facility
Florence, AL
4-star overall rating with 3-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Florence Nursing And Rehabilitation Ctr, LLC
Florence, AL
3-star overall rating with 3-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Glenwood Center
Florence, AL
1-star overall rating with 1-star inspections with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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