Cycle 1
Health 2025-01-15 · Fire 2025-01-15
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Mc Lean, VA
Arleigh Burke Pavilion
5-star overall rating with 4-star inspections with 8 recent health deficiencies
1739 Kirby Road, Mc Lean, VA
(703) 506-6900
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
49
Certified beds
Average residents
40
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2012-12-17
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
0.94
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.77
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.86
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
5.58
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
4.93
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.73
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
5.56
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
23%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
747
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
64.38
Composite VBP score used to determine payment impact.
Payment multiplier
1.0189
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.23
Baseline 15.80% · Performance 20.40% · Measure score 2.23 · Achievement 2.23 · Improvement 0
Healthcare-associated infections
5.98
Baseline 4.93% · Performance 6.05% · Measure score 5.98 · Achievement 5.98 · Improvement 0
Total nurse turnover
8.98
Baseline 14.29% · Performance 26.98% · Measure score 8.98 · Achievement 8.98 · Improvement 0
Adjusted total nurse staffing
8.55
Baseline 5.49 hours · Performance 5.51 hours · Measure score 8.55 · Achievement 8.55 · Improvement 0.17
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.32% |
10.72%
2.4 pts better
|
No Different than the National Rate · Eligible stays 282 · Observed rate 4.61% · Lower 95% interval 6.44% |
| Discharge to community | 65.58% |
50.57%
15 pts better
|
Better than the National Rate · Eligible stays 283 · Observed rate 63.25% · Lower 95% interval 59.41% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 146 · Denominator 146 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 146 |
| Discharge self-care score | 61.21% |
53.69%
7.5 pts better
|
Numerator 71 · Denominator 116 |
| Discharge mobility score | 62.07% |
50.94%
11.1 pts better
|
Numerator 72 · Denominator 116 |
| Pressure ulcers or injuries, new or worsened | 2.74% |
2.29%
0.5 pts worse
|
Numerator 4 · Denominator 146 · Adjusted rate 2.62% |
| Healthcare-associated infections requiring hospitalization | 6.05% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 173 · Observed rate 4.05% · Lower 95% interval 3.73% |
| Staff COVID-19 vaccination coverage | 3.66% |
8.2%
4.5 pts worse
|
Numerator 6 · Denominator 164 |
| Staff flu vaccination coverage | 23.86% |
42%
18.1 pts worse
|
Numerator 42 · Denominator 176 |
| Discharge function score | 67.24% |
56.45%
10.8 pts better
|
Numerator 78 · Denominator 116 |
| Transfer of health information to provider | 96.15% |
95.95%
0.2 pts better
|
Numerator 50 · Denominator 52 |
| Transfer of health information to patient | 98.75% |
96.28%
2.5 pts better
|
Numerator 79 · Denominator 80 |
| Resident COVID-19 vaccinations up to date | 47.83% |
25.2%
22.6 pts better
|
Numerator 33 · Denominator 69 |
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 1.3 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.4
0.4 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.8% |
91.2%
2.6 pts better
|
93.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.9% · Q2 92.9% · Q3 93.1% · Q4 96.4% · 4Q avg 93.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
94.0%
2.7 pts better
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.4% |
3.6%
0.8 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.6% · Q3 6.9% · Q4 3.6% · 4Q avg 4.4% · 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 | 4.1% |
5.7%
1.6 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 4.0% · Q3 0.0% · Q4 3.8% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.0% |
20.2%
15.2 pts better
|
19.6%
14.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 3.8% · Q3 4.2% · Q4 3.8% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.1% |
15.0%
5.9 pts better
|
16.7%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.1% · 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 need for help with daily activities has increased | 3.2% |
15.7%
12.5 pts better
|
14.9%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 4.5% · Q4 4.2% · 4Q avg 3.2% · 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 | 2.7% |
1.6%
1.1 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 3.6% · Q4 3.6% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.0% |
22.2%
10.2 pts better
|
19.8%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 25.4% · Q3 7.6% · Q4 7.5% · 4Q avg 12.0% |
| Percentage of long-stay residents with pressure ulcers | 10.7% |
5.2%
5.5 pts worse
|
5.1%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 12.7% · Q3 15.0% · Q4 3.5% · 4Q avg 10.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.4% |
74.6%
16.8 pts better
|
81.7%
9.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.1% · Q2 95.5% · Q3 93.2% · Q4 82.7% · 4Q avg 91.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.7% |
11.7%
2 pts better
|
12.0%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.7% · Observed 8.3% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.2% |
1.2%
3 pts worse
|
1.6%
2.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 7.1% · Q3 2.1% · Q4 0.0% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.0% |
73.6%
18.4 pts better
|
79.7%
12.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.7% |
22.0%
7.3 pts better
|
23.9%
9.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.7% · Observed 12.5% · Expected 20.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-11 · Fire 2022-08-11
2 health deficiencies
Top issue: Administration (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-07-08 · Fire 2021-07-08
3 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-08-11
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 2022-10-11
D · Potential for more than minimal harm
2022-08-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-11
D · Potential for more than minimal harm
2022-08-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-11
D · Potential for more than minimal harm
2021-07-08
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 2021-09-09
D · Potential for more than minimal harm
2021-07-08
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2021-09-09
D · Potential for more than minimal harm
2021-07-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-09-09
D · Potential for more than minimal harm
2021-07-08
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2021-09-09
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-15
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-15
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-15
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-15
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 2025-02-11
D · Potential for more than minimal harm
2025-01-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-15
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-11
D · Potential for more than minimal harm
2022-08-11
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-08-26
D · Potential for more than minimal harm
2022-08-11
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2022-08-26
F · Potential for more than minimal harm
2021-07-08
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.
Corrected 2021-08-12
D · Potential for more than minimal harm
2021-07-08
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2021-08-12
D · Potential for more than minimal harm
2021-07-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-12
Penalties and ownership
What sits behind the stars
Ownership
Nmcgr
5% Or Greater Direct Ownership Interest · Organization
Mazza, Richard
Operational/Managerial Control · Individual
Mazza, Richard
Corporate Officer · Individual
Pottanat, Cissy
Operational/Managerial Control · Individual
Roe, Robert
Operational/Managerial Control · Individual
Roe, Robert
Corporate Officer · Individual
Vasquez Soto, Analisse
Operational/Managerial Control · Individual
Vinson Hall LLC
Operational/Managerial Control · Organization
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#2
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#3
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