Cycle 1
Health 2023-09-14 · Fire 2023-09-14
1 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Martinsville, VA
King's Grant Retirement Commun
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
350 King's Way Road, Martinsville, VA
(276) 634-1000
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
32
Certified beds
Average residents
28
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-11-30
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
1.03
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.33
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.68
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
5.04
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
2.35
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.45
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.03
CMS adjusted RN staffing hours
Adjusted total hours
5.03
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,673
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.87
Composite VBP score used to determine payment impact.
Payment multiplier
1.0098
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.52
Baseline 20.67% · Performance 19.80% · Measure score 3.52 · Achievement 3.52 · Improvement 1.88
Healthcare-associated infections
1.71
Baseline 5.86% · Performance 7.32% · Measure score 1.71 · Achievement 1.71 · Improvement 0
Total nurse turnover
10
Baseline 35.29% · Performance 22.86% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
6.72
Baseline 4.21 hours · Performance 4.99 hours · Measure score 6.72 · Achievement 6.72 · Improvement 4.48
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.65% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 11.11% · Lower 95% interval 5.97% |
| Discharge to community | 45.89% |
50.57%
4.7 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 44.9% · Lower 95% interval 35.82% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 28 · Denominator 28 |
| Falls with major injury | 3.57% |
0.77%
2.8 pts worse
|
Numerator 1 · Denominator 28 |
| Discharge self-care score | 59.26% |
53.69%
5.6 pts better
|
Numerator 16 · Denominator 27 |
| Discharge mobility score | 66.67% |
50.94%
15.7 pts better
|
Numerator 18 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 28 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.32% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 33 · Observed rate 6.06% · Lower 95% interval 3.72% |
| Staff COVID-19 vaccination coverage | 1.99% |
8.2%
6.2 pts worse
|
Numerator 4 · Denominator 201 |
| Staff flu vaccination coverage | 14.22% |
42%
27.8 pts worse
|
Numerator 29 · Denominator 204 |
| Discharge function score | 62.96% |
56.45%
6.5 pts better
|
Numerator 17 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · 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 1.1 · Expected 1.4 · 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 1.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 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% |
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 | 1.9% |
3.6%
1.7 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.0% · Q3 0.0% · Q4 3.7% · 4Q avg 1.9% · 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 | 4.0% |
5.7%
1.7 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 5.0% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.9% |
20.2%
3.3 pts better
|
19.6%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 15.0% · 4Q avg 16.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.4% |
15.0%
8.4 pts worse
|
16.7%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.4% · 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 | 15.0% |
17.5%
2.5 pts better
|
16.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.8% |
15.7%
3.1 pts worse
|
14.9%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.5%
0.4 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.8% · Q4 0.0% · 4Q avg 0.9% · 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 3.7% · Q2 0.0% · 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 | 32.9% |
22.2%
10.7 pts worse
|
19.8%
13.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.4% · Q2 34.3% · Q3 38.5% · Q4 24.7% · 4Q avg 32.9% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
5.2%
2.9 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.2% · Q3 3.3% · Q4 2.7% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
74.6%
25.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · 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 | 20.7% |
11.7%
9 pts worse
|
12.0%
8.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 17.9% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
73.6%
26.4 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
22.0%
2.3 pts worse
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 21.4% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-09-30 · Fire 2021-09-30
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-09-20 · Fire 2019-09-20
0 health deficiencies
No concentrated health issue counts in this cycle.
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-09-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-08
F · Potential for more than minimal harm
2021-09-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-11-22
F · Potential for more than minimal harm
2021-09-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-11-22
F · Potential for more than minimal harm
2021-09-30
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2021-11-22
F · Potential for more than minimal harm
2021-09-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-11-22
E · Potential for more than minimal harm
2021-09-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-11-22
E · Potential for more than minimal harm
2021-09-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-11-22
D · Potential for more than minimal harm
2021-09-30
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-11-22
D · Potential for more than minimal harm
2021-09-30
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-11-22
F · Potential for more than minimal harm
2019-09-20
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-10-29
F · Potential for more than minimal harm
2019-09-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-10-29
F · Potential for more than minimal harm
2019-09-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-29
F · Potential for more than minimal harm
2019-09-20
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-10-29
F · Potential for more than minimal harm
2019-09-20
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2019-10-29
F · Potential for more than minimal harm
2019-09-20
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2019-10-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-09-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-12-01
D · Potential for more than minimal harm
2021-09-30
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 2021-11-12
Penalties and ownership
What sits behind the stars
Ownership
Lyons, Joshua
Operational/Managerial Control · Individual
Rowe, James
Corporate Officer · Individual
Souter, James
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Mulberry Creek Nursing & Rehab Center
Martinsville, VA
4-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Stanleytown Health And Rehabilitation Center
Bassett, VA
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Martinsville Health And Rehab
Martinsville, VA
1-star overall rating with 2-star inspections with 9 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
Jump out