Cycle 1
Health 2024-02-22 · Fire 2024-02-22
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Ashburn, VA
Ashby Ponds Inc
4-star overall rating with 3-star inspections with $9,438 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
21160 Maple Branch Terrace, Ashburn, VA
(571) 291-6200
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
44
Certified beds
Average residents
43
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Erickson Senior Living
Operator or chain grouping
Approved since
2014-07-26
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
17 facilities
Chain averages 4 overall / 3 health / 5 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
1.31
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.56
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
4.53
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.97
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.05
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.77
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.34
CMS adjusted RN staffing hours
Adjusted total hours
4.63
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
893
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.41
Composite VBP score used to determine payment impact.
Payment multiplier
1.0173
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.10
Baseline 20.72% · Performance 19.53% · Measure score 4.10 · Achievement 4.10 · Improvement 2.71
Healthcare-associated infections
5.06
Baseline 7.23% · Performance 6.32% · Measure score 5.06 · Achievement 5.06 · Improvement 3.57
Total nurse turnover
10
Baseline 36.17% · Performance 24.07% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
5.80
Baseline 4.31 hours · Performance 4.73 hours · Measure score 5.80 · Achievement 5.80 · Improvement 2.33
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.32% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 118 · Observed rate 5.93% · Lower 95% interval 6.06% |
| Discharge to community | 49.16% |
50.57%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 111 · Observed rate 44.14% · Lower 95% interval 42.11% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 55 · Denominator 55 |
| Falls with major injury | 3.64% |
0.77%
2.9 pts worse
|
Numerator 2 · Denominator 55 |
| Discharge self-care score | 35.56% |
53.69%
18.1 pts worse
|
Numerator 16 · Denominator 45 |
| Discharge mobility score | 22.22% |
50.94%
28.7 pts worse
|
Numerator 10 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 9.09% |
2.29%
6.8 pts worse
|
Numerator 5 · Denominator 55 · Adjusted rate 7.21% |
| Healthcare-associated infections requiring hospitalization | 6.32% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 72 · Observed rate 4.17% · Lower 95% interval 3.53% |
| Staff COVID-19 vaccination coverage | 3.65% |
8.2%
4.5 pts worse
|
Numerator 5 · Denominator 137 |
| Staff flu vaccination coverage | 48.26% |
42%
6.3 pts better
|
Numerator 83 · Denominator 172 |
| Discharge function score | 20% |
56.45%
36.5 pts worse
|
Numerator 9 · Denominator 45 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 64% |
25.2%
38.8 pts better
|
Numerator 16 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.1 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.4
0.2 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.2% |
91.2%
2 pts better
|
93.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.9% · Q2 94.7% · Q3 94.4% · Q4 94.7% · 4Q avg 93.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.3% |
94.0%
1.3 pts better
|
95.5%
0.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.6%
0.2 pts better
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 5.3% · Q3 2.8% · Q4 2.6% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
15.7%
15 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
5.7%
1.1 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.9% · Q3 0.0% · Q4 11.1% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.8% |
20.2%
1.6 pts worse
|
19.6%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 20.7% · Q3 16.0% · Q4 29.6% · 4Q avg 21.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.4% |
15.0%
3.4 pts worse
|
16.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 19.0% · Q4 20.0% · 4Q avg 18.4% · 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 | 29.3% |
17.5%
11.8 pts worse
|
16.3%
13 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.4% |
15.7%
3.3 pts better
|
14.9%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 11.5% · Q3 4.5% · Q4 13.0% · 4Q avg 12.4% · 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 2.8% · Q2 0.0% · Q3 2.9% · Q4 5.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.2% |
22.2%
1 pts worse
|
19.8%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 32.7% · Q3 22.5% · Q4 17.6% · 4Q avg 23.2% |
| Percentage of long-stay residents with pressure ulcers | 8.3% |
5.2%
3.1 pts worse
|
5.1%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 7.4% · Q3 6.3% · Q4 6.2% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.1% |
74.6%
2.5 pts better
|
81.7%
4.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 82.0% · Q2 77.3% · Q3 78.6% · Q4 71.2% · 4Q avg 77.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
11.7%
5.7 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 5.7% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.2%
0.3 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.2% |
73.6%
19.6 pts better
|
79.7%
13.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 6.7% |
22.0%
15.3 pts better
|
23.9%
17.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 5.7% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-04-28 · Fire 2022-04-28
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2021-03-26 · Fire 2021-03-26
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-02-22
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 2024-09-13
D · Potential for more than minimal harm
2022-04-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-06-03
D · Potential for more than minimal harm
2022-04-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-06-03
D · Potential for more than minimal harm
2021-03-26
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 2021-05-20
D · Potential for more than minimal harm
2021-03-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-05-20
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-02-22
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 2024-04-05
E · Potential for more than minimal harm
2024-02-22
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-04-05
E · Potential for more than minimal harm
2024-02-22
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-04-05
E · Potential for more than minimal harm
2024-02-22
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 2024-04-05
E · Potential for more than minimal harm
2024-02-22
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 2024-04-05
D · Potential for more than minimal harm
2024-02-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-02-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-05
E · Potential for more than minimal harm
2022-04-28
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 2022-05-31
D · Potential for more than minimal harm
2022-04-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-31
E · Potential for more than minimal harm
2021-03-26
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 2021-05-10
D · Potential for more than minimal harm
2021-03-26
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 2021-05-10
D · Potential for more than minimal harm
2021-03-26
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 2021-05-10
D · Potential for more than minimal harm
2021-03-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-05-10
D · Potential for more than minimal harm
2021-03-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-05-10
D · Potential for more than minimal harm
2021-03-26
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2021-05-10
D · Potential for more than minimal harm
2021-03-26
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-05-10
D · Potential for more than minimal harm
2021-03-26
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-05-10
Penalties and ownership
What sits behind the stars
$2,447
2023-10-10
Fine
Fine · fine $2,447
Fine
$2,098
2023-10-02
Fine
Fine · fine $2,098
Fine
$1,748
2023-09-25
Fine
Fine · fine $1,748
Fine
$3,145
2023-09-05
Fine
Fine · fine $3,145
Fine
Ownership
National Senior Communities, Inc
5% Or Greater Direct Ownership Interest · Organization
Oak Investment Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Oak Investment Trust
5% Or Greater Indirect Ownership Interest · Organization
Brown, Ian
Corporate Director · Individual
Brown, Patricia
Corporate Director · Individual
Butler, Richard
Operational/Managerial Control · Individual
Clupper, Katherine
Corporate Director · Individual
Colins, Mary
Corporate Director · Individual
Colins, Mary
Corporate Officer · Individual
Embley, Mark
Operational/Managerial Control · Individual
Embley, Mark
Corporate Officer · Individual
Erickson Senior Living LLC
Operational/Managerial Control · Organization
Erstad, Eileen
Corporate Director · Individual
Erstad, Eileen
Corporate Officer · Individual
Gantert, Neal
Operational/Managerial Control · Individual
Gantert, Neal
Corporate Officer · Individual
Hall, John
Operational/Managerial Control · Individual
Hall, John
Corporate Officer · Individual
Jacque, Zina
Corporate Director · Individual
Kotwal, Shaveta
Operational/Managerial Control · Individual
Leonard, Monty
Corporate Director · Individual
Leonard, Monty
Corporate Officer · Individual
Moscato, Mary
Corporate Director · Individual
National Senior Communities, Inc
Operational/Managerial Control · Organization
Paulk, Pamela
Corporate Director · Individual
Pomeranz, William
Corporate Director · Individual
Rebholtz, Carla
Operational/Managerial Control · Individual
Reel, Stephanie
Corporate Director · Individual
Roskiewicz, Michael
Corporate Director · Individual
Sawicki, Scott
Corporate Officer · Individual
Sharp, Russel
Corporate Director · Individual
Stiner, Pamela
Operational/Managerial Control · Individual
Stiner, Pamela
Corporate Officer · Individual
Sweetser, Christian
Operational/Managerial Control · Individual
Tyler, Daniel
Corporate Officer · Individual
Wallick, Daniel
Corporate Director · Individual
Wallick, Daniel
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Potomac Falls Health & Rehab Center
Sterling, VA
3-star overall rating with 3-star inspections with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Johnson Cntr/Falcons Landing
Potomac Falls, VA
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Dulles Health & Rehab Center
Herndon, VA
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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