Cycle 1
Health 2024-03-14 · Fire 2024-03-14
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Madison, MS
The Nichols Center
2-star overall rating with 2-star inspections with $7,901 in total fines with 5 recent health deficiencies
1308 Highway 51 North, Madison, MS
(601) 853-4343
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
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Briar Hill Management
Operator or chain grouping
Approved since
2003-12-15
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
0.63
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.21
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.88
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
4.73
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.84
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
4.13
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.75
CMS adjusted RN staffing hours
Adjusted total hours
5.64
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,585
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.65
Composite VBP score used to determine payment impact.
Payment multiplier
0.9893
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.24% · Performance 26.95% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.24
Baseline 13.37% · Performance 7.72% · Measure score 6.24 · Achievement 0 · Improvement 6.24
Total nurse turnover
1.74
Baseline 46.00% · Performance 56.58% · Measure score 1.74 · Achievement 1.74 · Improvement 0
Adjusted total nurse staffing
6.28
Baseline 4.15 hours · Performance 4.87 hours · Measure score 6.28 · Achievement 6.28 · Improvement 3.87
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.08% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 253 · Observed rate 13.04% · Lower 95% interval 8.93% |
| Discharge to community | 53.48% |
50.57%
2.9 pts better
|
No Different than the National Rate · Eligible stays 276 · Observed rate 47.83% · Lower 95% interval 47.18% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 192 · Denominator 192 |
| Falls with major injury | 1.56% |
0.77%
0.8 pts worse
|
Numerator 3 · Denominator 192 |
| Discharge self-care score | 65.42% |
53.69%
11.7 pts better
|
Numerator 70 · Denominator 107 |
| Discharge mobility score | 63.55% |
50.94%
12.6 pts better
|
Numerator 68 · Denominator 107 |
| Pressure ulcers or injuries, new or worsened | 2.08% |
2.29%
0.2 pts better
|
Numerator 4 · Denominator 192 · Adjusted rate 2.39% |
| Healthcare-associated infections requiring hospitalization | 7.73% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 173 · Observed rate 7.51% · Lower 95% interval 5.32% |
| Staff COVID-19 vaccination coverage | 2.25% |
8.2%
5.9 pts worse
|
Numerator 2 · Denominator 89 |
| Staff flu vaccination coverage | 14.44% |
42%
27.6 pts worse
|
Numerator 13 · Denominator 90 |
| Discharge function score | 69.16% |
56.45%
12.7 pts better
|
Numerator 74 · Denominator 107 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 112 · Denominator 112 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 57 · Denominator 57 |
| Resident COVID-19 vaccinations up to date | 5.56% |
25.2%
19.6 pts worse
|
Numerator 5 · Denominator 90 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.3 |
2.4
1.9 pts worse
|
1.9
2.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.3 · Observed 4.4 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.4 |
2.9
0.5 pts worse
|
1.8
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.3 · Expected 1.6 · 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 | 2.8% |
3.2%
0.4 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 5.3% · Q4 2.6% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.6%
1.6 pts better
|
11.4%
11.4 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 who lose too much weight | 7.5% |
6.1%
1.4 pts worse
|
5.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 3.0% · Q3 8.6% · Q4 11.8% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.3% |
24.4%
0.1 pts better
|
19.6%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 26.5% · Q3 26.3% · Q4 18.4% · 4Q avg 24.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.2% |
23.4%
3.8 pts worse
|
16.7%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 25.0% · Q3 26.7% · Q4 25.0% · 4Q avg 27.2% · 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 | 34.1% |
22.8%
11.3 pts worse
|
16.3%
17.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 34.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.0% |
20.6%
5.4 pts worse
|
14.9%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 25.0% · Q3 26.5% · Q4 41.2% · 4Q avg 26.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.5%
0.5 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 2.1% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.5%
2.5 pts better
|
1.7%
1.7 pts better
|
Long 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 long-stay residents with new or worsened bowel or bladder incontinence | 19.0% |
21.4%
2.4 pts better
|
19.8%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 21.4% · Q3 13.5% · Q4 34.2% · 4Q avg 19.0% |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
6.9%
0.2 pts better
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 10.5% · Q3 3.2% · Q4 3.2% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
87.9%
10.8 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 97.7% · Q3 99.1% · Q4 100.0% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.9% |
15.3%
0.4 pts better
|
12.0%
2.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.9% · Observed 13.7% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
2.6%
2 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.3% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.3% |
84.6%
11.7 pts better
|
79.7%
16.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.8% |
27.9%
6.9 pts worse
|
23.9%
10.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.8% · Observed 30.4% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-01 · Fire 2022-12-01
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-12-04 · Fire 2019-12-04
8 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-25
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 2025-12-06
G · Actual harm
2025-10-22
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 2025-11-08
D · Potential for more than minimal harm
2024-03-14
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 2024-04-15
D · Potential for more than minimal harm
2024-03-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-03-14
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 2024-04-15
G · Actual harm
2024-01-10
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 2023-12-21
G · Actual harm
2024-01-10
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 2023-12-21
G · Actual harm
2024-01-10
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 2023-12-21
D · Potential for more than minimal harm
2023-12-18
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-01-26
E · Potential for more than minimal harm
2022-12-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-06
E · Potential for more than minimal harm
2019-12-04
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 2020-01-04
D · Potential for more than minimal harm
2019-12-04
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 2020-01-04
D · Potential for more than minimal harm
2019-12-04
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 2020-01-04
D · Potential for more than minimal harm
2019-12-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-01-04
Penalties and ownership
What sits behind the stars
$0
2025-10-22
Payment Denial
Payment Denial · denial start 2025-11-11 · 26 days
26 day denial
$7,901
2023-12-18
Fine
Fine · fine $7,901
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
Duncan, Kristi
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
Trustmark National Bank
Operational/Managerial Control · Organization
Trustmark National Bank
5% Or Greater Security Interest · Organization
Trustmark National Bank
5% Or Greater Mortgage Interest · Organization
White, Deborah
Operational/Managerial Control · Individual
Whitlow, Carrie
Operational/Managerial Control · Individual
Woodard, Lisha
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
The Madison Health And Rehab
Madison, MS
3-star overall rating with 3-star inspections with 8 recent health deficiencies
#2
Highland Home
Ridgeland, MS
2-star overall rating with 2-star inspections with $10,033 in total fines with 7 recent health deficiencies
#3
Parkway Health & Rehab LLC
Canton, MS
1-star overall rating with 2-star inspections with $8,278 in total fines with 12 recent health deficiencies
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