Cycle 1
Health 2024-10-17 · Fire 2024-10-17
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lebanon, VA
Maple Grove Nursing & Rehab Center
3-star overall rating with 3-star inspections with 9 recent health deficiencies
318 South East Main Street, Lebanon, VA
(276) 889-0733
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
60
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Kissito Healthcare
Operator or chain grouping
Approved since
2002-11-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 4 overall / 4 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.00
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
4.05
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.51
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.03
CMS adjusted RN staffing hours
Adjusted total hours
4.19
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,691
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.02
Composite VBP score used to determine payment impact.
Payment multiplier
0.9868
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.13% · Performance 22.01% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.49
Baseline 9.30% · Performance 7.15% · Measure score 4.49 · Achievement 2.28 · Improvement 4.49
Total nurse turnover
6.26
Baseline 45.95% · Performance 38.09% · Measure score 6.26 · Achievement 6.26 · Improvement 3.22
Adjusted total nurse staffing
2.06
Baseline 3.57 hours · Performance 3.66 hours · Measure score 2.06 · Achievement 2.06 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.73% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 157 · Observed rate 13.38% · Lower 95% interval 8.94% |
| Discharge to community | 61.79% |
50.57%
11.2 pts better
|
Better than the National Rate · Eligible stays 159 · Observed rate 57.23% · Lower 95% interval 53.74% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 99 · Denominator 99 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 99 |
| Discharge self-care score | 60.56% |
53.69%
6.9 pts better
|
Numerator 43 · Denominator 71 |
| Discharge mobility score | 59.15% |
50.94%
8.2 pts better
|
Numerator 42 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 5.05% |
2.29%
2.8 pts worse
|
Numerator 5 · Denominator 99 · Adjusted rate 5.72% |
| Healthcare-associated infections requiring hospitalization | 7.15% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 96 · Observed rate 7.29% · Lower 95% interval 4.41% |
| Staff COVID-19 vaccination coverage | 3.57% |
8.2%
4.6 pts worse
|
Numerator 4 · Denominator 112 |
| Staff flu vaccination coverage | 39.73% |
42%
2.3 pts worse
|
Numerator 58 · Denominator 146 |
| Discharge function score | 67.61% |
56.45%
11.2 pts better
|
Numerator 48 · Denominator 71 |
| Transfer of health information to provider | 98.41% |
95.95%
2.5 pts better
|
Numerator 62 · Denominator 63 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 16.67% |
25.2%
8.5 pts worse
|
Numerator 7 · Denominator 42 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.5
0.1 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.9 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.4
1.2 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.9 · Expected 1.9 · 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 | 7.9% |
3.6%
4.3 pts worse
|
3.3%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.5% · Q3 11.1% · Q4 13.5% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.9% |
15.7%
6.8 pts better
|
11.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 17.4% · Q3 6.2% · Q4 12.5% · 4Q avg 8.9% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
5.7%
2.1 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 7.9% · Q3 3.0% · Q4 0.0% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 49.0% |
20.2%
28.8 pts worse
|
19.6%
29.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 51.4% · Q2 56.4% · Q3 40.0% · Q4 47.2% · 4Q avg 49.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.2% |
15.0%
5.2 pts worse
|
16.7%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 22.6% · Q3 20.0% · Q4 22.6% · 4Q avg 20.2% · 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 | 27.7% |
17.5%
10.2 pts worse
|
16.3%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.1% |
15.7%
12.4 pts worse
|
14.9%
13.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 38.2% · Q3 23.3% · Q4 28.1% · 4Q avg 28.1% · 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 · 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 a urinary tract infection | 2.1% |
1.6%
0.5 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 6.1% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.6% |
22.2%
0.4 pts worse
|
19.8%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 19.3% · Q3 27.9% · Q4 20.3% · 4Q avg 22.6% |
| Percentage of long-stay residents with pressure ulcers | 8.7% |
5.2%
3.5 pts worse
|
5.1%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 5.0% · Q3 11.5% · Q4 16.9% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.0% |
74.6%
15.4 pts better
|
81.7%
8.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 82.2% · Q2 88.8% · Q3 92.6% · Q4 95.0% · 4Q avg 90.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.5% |
11.7%
1.8 pts worse
|
12.0%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.5% · Observed 13.6% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.2%
0.5 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.8% |
73.6%
10.2 pts better
|
79.7%
4.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.7% |
22.0%
1.3 pts better
|
23.9%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 23.5% · Expected 27.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-05-17 · Fire 2022-05-17
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2020-03-12 · Fire 2020-03-12
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-05-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-09-02
E · Potential for more than minimal harm
2022-05-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-05-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-05-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-08-12
E · Potential for more than minimal harm
2020-03-12
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2020-10-13
Inspection history
Recent health citations
G · Actual harm
2025-10-21
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 2025-07-07
E · Potential for more than minimal harm
2024-10-17
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 2024-11-22
E · Potential for more than minimal harm
2024-10-17
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-17
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-17
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 2024-11-22
D · Potential for more than minimal harm
2024-10-17
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 2024-11-22
D · Potential for more than minimal harm
2024-10-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-22
D · Potential for more than minimal harm
2022-05-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-07-12
D · Potential for more than minimal harm
2020-03-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-04-23
D · Potential for more than minimal harm
2020-03-12
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 2020-04-23
D · Potential for more than minimal harm
2020-03-12
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 2020-04-23
D · Potential for more than minimal harm
2020-03-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-04-23
Penalties and ownership
What sits behind the stars
Ownership
Ferrell, Mary
Operational/Managerial Control · Individual
Mcclintic Operations Holdco Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Mcclintic Operations Holdco Ii LLC
Operational/Managerial Control · Organization
Mcclintic Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Mcclintic Operations LLC
Operational/Managerial Control · Organization
Mcclintic, Robert
5% Or Greater Indirect Ownership Interest · Individual
Mcclintic, Robert
Operational/Managerial Control · Individual
Perry, Katie
Operational/Managerial Control · Individual
Rbm Of Lebanon LLC
5% Or Greater Direct Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Deer Meadows Rehabilitation And Nursing
Abingdon, VA
1-star overall rating with 1-star inspections with 36 recent health deficiencies
#2
Abingdon Health Care LLC
Abingdon, VA
5-star overall rating with 5-star inspections with 3 recent health deficiencies
#3
The Rehab Center At Bristol
Bristol, VA
1-star overall rating with 2-star inspections with $10,358 in total fines with 14 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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