Cycle 1
Health 2024-08-14 · Fire 2024-08-14
4 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Marion, VA
Francis Marion Manor Health & Rehabilitation
4-star overall rating with 4-star inspections with 4 recent health deficiencies
100 Francis Marion Lane, Marion, VA
(276) 782-1396
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
109
Certified beds
Average residents
53
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2005-06-01
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.95
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.76
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.65
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.89
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.89
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
3.34
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
602
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
66.72
Composite VBP score used to determine payment impact.
Payment multiplier
1.0205
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
5.34
Baseline 50.88% · Performance 41.86% · Measure score 5.34 · Achievement 5.34 · Improvement 2.96
Adjusted total nurse staffing
8.01
Baseline 3.10 hours · Performance 5.36 hours · Measure score 8.01 · Achievement 8.01 · Improvement 7.92
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 5 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 2 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 9.46% |
8.2%
1.3 pts better
|
Numerator 7 · Denominator 74 |
| Staff flu vaccination coverage | 95.56% |
42%
53.6 pts better
|
Numerator 86 · Denominator 90 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.4
0.1 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
91.2%
7.8 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 96.9% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.0%
6 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 | 3.1% |
3.6%
0.5 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · Q3 4.5% · Q4 3.1% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
15.7%
15.7 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 | 2.4% |
5.7%
3.3 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 5.0% · Q4 0.0% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 46.0% |
20.2%
25.8 pts worse
|
19.6%
26.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 55.0% · Q3 55.0% · Q4 35.7% · 4Q avg 46.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.1% |
15.0%
14.1 pts worse
|
16.7%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 30.0% · Q4 29.2% · 4Q avg 29.1% · 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 | 35.6% |
17.5%
18.1 pts worse
|
16.3%
19.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.0% |
15.7%
16.3 pts worse
|
14.9%
17.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 29.2% · 4Q avg 32.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.6%
0.6 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.9% |
22.2%
4.7 pts worse
|
19.8%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 26.4% · 4Q avg 26.9% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
5.2%
3.1 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 4.6% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.5% |
74.6%
14.9 pts better
|
81.7%
7.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 80.0% · Q4 93.4% · 4Q avg 89.5% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.6% |
1.2%
2.4 pts worse
|
1.6%
2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q4 2.4% · 4Q avg 3.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-11-04 · Fire 2021-11-04
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2020-02-21 · Fire 2020-02-21
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2021-11-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-01-07
F · Potential for more than minimal harm
2021-11-04
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2022-01-07
F · Potential for more than minimal harm
2021-11-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-01-07
E · Potential for more than minimal harm
2021-11-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-01-07
E · Potential for more than minimal harm
2021-11-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-01-07
E · Potential for more than minimal harm
2021-11-04
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-01-07
D · Potential for more than minimal harm
2021-11-04
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-01-07
D · Potential for more than minimal harm
2021-11-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-01-07
D · Potential for more than minimal harm
2021-11-04
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-01-07
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-08-14
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-08-14
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-08-14
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-08-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-10-15
D · Potential for more than minimal harm
2021-11-04
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2021-12-19
D · Potential for more than minimal harm
2021-11-04
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-12-19
D · Potential for more than minimal harm
2021-11-04
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-12-19
D · Potential for more than minimal harm
2020-02-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-03-06
D · Potential for more than minimal harm
2020-02-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-06
Penalties and ownership
What sits behind the stars
Ownership
Ahava Hc LLC
Operational/Managerial Control · Organization
Clampitt, Robert
Operational/Managerial Control · Individual
Francis Marion Realty Group LLC
5% Or Greater Mortgage Interest · Organization
Niederman, Anshel
Operational/Managerial Control · Individual
Taylor, Stacy
Operational/Managerial Control · Individual
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#3
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