Cycle 1
Health 2024-05-09 · Fire 2024-05-09
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Martinsville, VA
Mulberry Creek Nursing & Rehab Center
4-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
300 Blue Ridge Street, Martinsville, VA
(540) 265-0322
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
300
Certified beds
Average residents
186
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Kissito Healthcare
Operator or chain grouping
Approved since
2020-01-31
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
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.42
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.75
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
3.54
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
24%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,864
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9886
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.45
Baseline 18.94% · Performance 20.29% · Measure score 2.45 · Achievement 2.45 · Improvement 0
Healthcare-associated infections
5.68
Baseline 11.34% · Performance 7.42% · Measure score 5.68 · Achievement 1.39 · Improvement 5.68
Total nurse turnover
4.80
Baseline 47.71% · Performance 44.07% · Measure score 4.80 · Achievement 4.80 · Improvement 1.09
Adjusted total nurse staffing
0.98
Baseline 3.52 hours · Performance 3.36 hours · Measure score 0.98 · Achievement 0.98 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.81% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 143 · Observed rate 10.49% · Lower 95% interval 7.33% |
| Discharge to community | 44.2% |
50.57%
6.4 pts worse
|
No Different than the National Rate · Eligible stays 144 · Observed rate 37.5% · Lower 95% interval 38% |
| Medicare spending per beneficiary | 1.34 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 115 · Denominator 115 |
| Falls with major injury | 4.35% |
0.77%
3.6 pts worse
|
Numerator 5 · Denominator 115 |
| Discharge self-care score | 47.67% |
53.69%
6 pts worse
|
Numerator 41 · Denominator 86 |
| Discharge mobility score | 58.14% |
50.94%
7.2 pts better
|
Numerator 50 · Denominator 86 |
| Pressure ulcers or injuries, new or worsened | 7.83% |
2.29%
5.5 pts worse
|
Numerator 9 · Denominator 115 · Adjusted rate 7.04% |
| Healthcare-associated infections requiring hospitalization | 7.42% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 127 · Observed rate 8.66% · Lower 95% interval 4.63% |
| Staff COVID-19 vaccination coverage | 6.69% |
8.2%
1.5 pts worse
|
Numerator 20 · Denominator 299 |
| Staff flu vaccination coverage | 16.47% |
42%
25.5 pts worse
|
Numerator 55 · Denominator 334 |
| Discharge function score | 56.98% |
56.45%
0.5 pts better
|
Numerator 49 · Denominator 86 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | 97.87% |
96.28%
1.6 pts better
|
Numerator 46 · Denominator 47 |
| Resident COVID-19 vaccinations up to date | 24.56% |
25.2%
0.6 pts worse
|
Numerator 14 · Denominator 57 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.5
0.1 pts worse
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.4
0.3 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
91.2%
3.7 pts better
|
93.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 91.6% · Q2 96.4% · Q3 95.4% · Q4 96.0% · 4Q avg 94.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.4% |
94.0%
4.4 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.7% |
3.6%
2.1 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 6.6% · Q3 4.6% · Q4 5.1% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
15.7%
14.9 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.7% · Q3 0.0% · Q4 0.6% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 8.8% |
5.7%
3.1 pts worse
|
5.4%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 10.0% · Q3 7.1% · Q4 4.7% · 4Q avg 8.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.3% |
20.2%
6.1 pts worse
|
19.6%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 25.3% · Q3 25.4% · Q4 28.7% · 4Q avg 26.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.0% |
15.0%
6 pts worse
|
16.7%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 23.8% · Q3 20.0% · Q4 15.9% · 4Q avg 21.0% · 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 | 21.5% |
17.5%
4 pts worse
|
16.3%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.4% · Q2 24.5% · Q3 13.6% · Q4 19.0% · 4Q avg 21.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.7% |
15.7%
5 pts worse
|
14.9%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 33.8% · Q3 14.6% · Q4 15.2% · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.5%
0.5 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.6% · Q3 0.8% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
1.6%
0.4 pts worse
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.2% · Q3 2.3% · Q4 1.7% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.4% |
22.2%
0.2 pts worse
|
19.8%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 20.2% · Q3 26.0% · Q4 23.4% · 4Q avg 22.4% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
5.2%
2.3 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 9.7% · Q3 7.8% · Q4 6.2% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.4% |
74.6%
5.8 pts better
|
81.7%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.7% · Q2 77.9% · Q3 81.6% · Q4 86.5% · 4Q avg 80.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.9% |
11.7%
3.2 pts worse
|
12.0%
2.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.9% · Observed 14.6% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.2%
0.7 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.2% · Q3 1.4% · Q4 2.8% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.9% |
73.6%
14.3 pts better
|
79.7%
8.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.1% |
22.0%
6.1 pts worse
|
23.9%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.1% · Observed 28.2% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-05 · Fire 2022-12-05
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2020-01-30 · Fire 2020-01-30
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.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-05-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-24
F · Potential for more than minimal harm
2022-12-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-27
F · Potential for more than minimal harm
2022-12-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-27
F · Potential for more than minimal harm
2022-12-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Not marked corrected
E · Potential for more than minimal harm
2022-12-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-27
E · Potential for more than minimal harm
2022-12-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-27
E · Potential for more than minimal harm
2022-12-05
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-01-27
E · Potential for more than minimal harm
2022-12-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-27
D · Potential for more than minimal harm
2022-12-05
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-01-27
D · Potential for more than minimal harm
2022-12-05
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-01-27
D · Potential for more than minimal harm
2022-12-05
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-01-27
D · Potential for more than minimal harm
2022-12-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-01-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-15
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 2024-12-11
D · Potential for more than minimal harm
2024-08-21
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 2024-10-11
D · Potential for more than minimal harm
2024-05-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-07-18
D · Potential for more than minimal harm
2023-04-04
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-06-26
D · Potential for more than minimal harm
2023-04-04
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 2023-06-26
D · Potential for more than minimal harm
2023-04-04
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 2023-06-26
E · Potential for more than minimal harm
2022-12-05
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.
Not marked corrected
D · Potential for more than minimal harm
2022-12-05
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.
Not marked corrected
D · Potential for more than minimal harm
2022-12-05
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-02-14
D · Potential for more than minimal harm
2022-12-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-02-14
D · Potential for more than minimal harm
2022-12-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Not marked corrected
D · Potential for more than minimal harm
2022-12-05
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.
Not marked corrected
D · Potential for more than minimal harm
2020-01-30
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 2020-01-31
D · Potential for more than minimal harm
2020-01-30
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 2020-01-31
Penalties and ownership
What sits behind the stars
Ownership
Ferrell, Mary
Operational/Managerial Control · Individual
Mcclintic Operations Holdco I LLC
5% Or Greater Indirect Ownership Interest · Organization
Mcclintic Operations Holdco I LLC
Operational/Managerial Control · Organization
Mcclintic Operations Holdco Ii LLC
Operational/Managerial Control · Organization
Mcclintic, Robert
5% Or Greater Indirect Ownership Interest · Individual
Mcclintic, Robert
Operational/Managerial Control · Individual
Ohi Asset (Va) Martinsville SNF, LLC
5% Or Greater Security Interest · Organization
Perry, Katie
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
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
#2
King's Grant Retirement Commun
Martinsville, VA
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
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
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