Cycle 1
Health 2023-08-31 · Fire 2023-08-31
2 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Marion, VA
Sw Va M H Inst Geri Trt Ctr
5-star overall rating with 4-star inspections with 2 recent health deficiencies
340 Bagley Circle, Marion, VA
(276) 783-1209
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
25
Certified beds
Average residents
20
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1974-03-31
CMS approved date
Coverage
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
2.21
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.43
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
5.15
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
2.72
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.54
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
1.82
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
3.24
CMS adjusted RN staffing hours
Adjusted total hours
7.52
CMS adjusted total nurse staffing hours
Case-mix index
0.94
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
15%
Annual nurse turnover · state 48% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data. |
| Medicare spending per beneficiary | Not Available |
1.02
|
This provider is not required to submit SNF QRP data. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · This provider is not required to submit SNF QRP data. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.5% |
91.2%
3.7 pts worse
|
93.4%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 80.0% · 4Q avg 87.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 76.2% |
94.0%
17.8 pts worse
|
95.5%
19.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 76.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.6%
0.8 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.4% |
15.7%
10.3 pts better
|
11.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.4% |
| Percentage of long-stay residents who lose too much weight | 9.2% |
5.7%
3.5 pts worse
|
5.4%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.7% |
20.2%
0.5 pts better
|
19.6%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 90.9% |
15.0%
75.9 pts worse
|
16.7%
74.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 90.9% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.5% |
17.5%
11 pts better
|
16.3%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.9% |
15.7%
7.8 pts better
|
14.9%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.9% · 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.6%
0.2 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.6% |
22.2%
18.6 pts better
|
19.8%
16.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · 4Q avg 3.6% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
5.2%
5.2 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
74.6%
20.3 pts better
|
81.7%
13.2 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 94.9% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-02-26 · Fire 2021-02-26
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2019-03-14 · Fire 2019-03-14
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.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2021-02-26
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-05-12
E · Potential for more than minimal harm
2021-02-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-05-12
E · Potential for more than minimal harm
2021-02-26
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-05-12
E · Potential for more than minimal harm
2021-02-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-05-12
D · Potential for more than minimal harm
2021-02-26
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2021-05-12
D · Potential for more than minimal harm
2021-02-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-05-12
Inspection history
Recent health citations
F · Potential for more than minimal harm
2023-08-31
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 2024-01-23
D · Potential for more than minimal harm
2023-08-31
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 2024-01-23
E · Potential for more than minimal harm
2021-02-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-04-01
E · Potential for more than minimal harm
2019-03-14
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 2019-04-26
D · Potential for more than minimal harm
2019-03-14
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2019-04-26
D · Potential for more than minimal harm
2019-03-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-04-26
D · Potential for more than minimal harm
2019-03-14
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 2019-04-26
C · Minimal harm
2019-03-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-04-26
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Francis Marion Manor Health & Rehabilitation
Marion, VA
4-star overall rating with 4-star inspections with 4 recent health deficiencies
#2
Valley Rehabilitation And Nursing Center
Chilhowie, VA
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Mountain Laurel Rehabilitation And Nursing
Rural Retreat, VA
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $204,839 in total fines with 56 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Jump out