Hot Springs, VA
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
167 Spring Street, Hot Springs, VA
(540) 839-2299
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
60
Certified beds
Average residents
56
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Kissito Healthcare
Operator or chain grouping
Approved since
1990-09-28
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
RN hours / resident day
0.70
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.51
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.16
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.84
CMS adjusted RN staffing hours
Adjusted total hours
4.18
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
8,029
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.02
Composite VBP score used to determine payment impact.
Payment multiplier
0.9848
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
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
1.40
Baseline 63.64% · Performance 57.97% · Measure score 1.40 · Achievement 1.40 · Improvement 0.96
Adjusted total nurse staffing
4.21
Baseline 3.61 hours · Performance 4.27 hours · Measure score 4.21 · Achievement 4.21 · Improvement 2.58
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 15 · 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 10 · 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 12 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 12 · 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 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 8.24% |
8.2%
About the same
|
Numerator 7 · Denominator 85 |
| Staff flu vaccination coverage | 18.12% |
42%
23.9 pts worse
|
Numerator 25 · Denominator 138 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.5
0.6 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.6 · Expected 1.3 · 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 1.3 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
91.2%
8.3 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.1% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| 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 | 4.7% |
3.6%
1.1 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 7.5% · Q3 3.8% · Q4 0.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 17.5% |
15.7%
1.8 pts worse
|
11.4%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 18.0% · Q3 16.7% · Q4 17.3% · 4Q avg 17.5% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
5.7%
3.6 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 4.3% · Q4 2.6% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.7% |
20.2%
10.5 pts worse
|
19.6%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 31.4% · Q3 31.9% · Q4 35.0% · 4Q avg 30.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.6% |
15.0%
9.6 pts worse
|
16.7%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 24.2% · Q3 27.8% · Q4 23.5% · 4Q avg 24.6% · 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 | 12.3% |
17.5%
5.2 pts better
|
16.3%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 15.9% · Q3 16.2% · Q4 3.8% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.3% |
15.7%
5.4 pts better
|
14.9%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 12.8% · Q3 14.0% · Q4 5.6% · 4Q avg 10.3% · 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 | 1.4% |
1.6%
0.2 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.9% · Q3 0.0% · Q4 1.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.7% |
22.2%
1.5 pts worse
|
19.8%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 29.3% · Q3 28.7% · Q4 24.6% · 4Q avg 23.7% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
5.2%
1.9 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 3.0% · Q3 2.7% · Q4 2.1% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.7% |
74.6%
16.1 pts better
|
81.7%
9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q4 95.2% · 4Q avg 90.7% |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Resident Assessment and Care Planning (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-08
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-02-08
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-06
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-24
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 2022-10-17
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-06
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-06
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-10-17
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-10-17
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-05-25
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-05-25
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-05-25
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-05-25
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-20
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-20
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-20
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-20
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-09-13
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2022-09-13
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-09-13
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-09-13
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-09-13
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-09-13
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2021-04-26
Health
Respond appropriately to all alleged violations.
Corrected 2021-04-26
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 2021-04-26
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-04-26
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 2021-04-26
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
W-2 Managing Employee · Individual
Corporate Officer · Individual
Corporate Officer · Individual
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