Cycle 1
Health 2023-06-29 · Fire 2023-06-29
11 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Burke, VA
Burke Health & Rehabilitation Center
3-star overall rating with 3-star inspections with 11 recent health deficiencies
9640 Burke Lake Road, Burke, VA
(703) 425-9765
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
116
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
1991-08-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
59 facilities
Chain averages 2 overall / 2 health / 2 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
0.54
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.66
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.18
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.64
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.25
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
2.64
CMS adjusted total nurse staffing hours
Case-mix index
1.65
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,347
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9833
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.51
Baseline 22.98% · Performance 20.00% · Measure score 4.51 · Achievement 3.09 · Improvement 4.51
Healthcare-associated infections
0
Baseline 7.54% · Performance 8.14% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.06
Performance 42.99% · Measure score 5.06 · Achievement 5.06 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.26 hours · Performance 3.05 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.69% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 803 · Observed rate 11.21% · Lower 95% interval 9.38% |
| Discharge to community | 61.66% |
50.57%
11.1 pts better
|
Better than the National Rate · Eligible stays 900 · Observed rate 54% · Lower 95% interval 58.18% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.42% |
95.27%
4.2 pts better
|
Numerator 513 · Denominator 516 |
| Falls with major injury | 1.55% |
0.77%
0.8 pts worse
|
Numerator 8 · Denominator 516 |
| Discharge self-care score | 78.21% |
53.69%
24.5 pts better
|
Numerator 244 · Denominator 312 |
| Discharge mobility score | 76.6% |
50.94%
25.7 pts better
|
Numerator 239 · Denominator 312 |
| Pressure ulcers or injuries, new or worsened | 2.13% |
2.29%
0.2 pts better
|
Numerator 11 · Denominator 516 · Adjusted rate 1.78% |
| Healthcare-associated infections requiring hospitalization | 8.14% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 531 · Observed rate 8.85% · Lower 95% interval 6.5% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 150 |
| Staff flu vaccination coverage | 38.79% |
42%
3.2 pts worse
|
Numerator 64 · Denominator 165 |
| Discharge function score | 76.6% |
56.45%
20.1 pts better
|
Numerator 239 · Denominator 312 |
| Transfer of health information to provider | 96.02% |
95.95%
0.1 pts better
|
Numerator 217 · Denominator 226 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 264 · Denominator 264 |
| Resident COVID-19 vaccinations up to date | 46.55% |
25.2%
21.3 pts better
|
Numerator 128 · Denominator 275 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.4
0.8 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 5.1% |
3.6%
1.5 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 6.8% · Q3 6.8% · Q4 0.0% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.9% |
15.7%
0.8 pts better
|
11.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.9% · Q2 2.4% · Q3 5.3% · Q4 17.1% · 4Q avg 14.9% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.7%
0.4 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 7.3% · Q3 7.0% · Q4 5.3% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.2% |
20.2%
5 pts better
|
19.6%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 16.7% · Q3 16.3% · Q4 10.5% · 4Q avg 15.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.6% |
15.0%
5.4 pts better
|
16.7%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 8.8% · Q3 6.1% · Q4 6.7% · 4Q avg 9.6% · 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 | 3.5% |
17.5%
14 pts better
|
16.3%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 5.0% · Q3 4.2% · Q4 0.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.4% |
15.7%
13.3 pts better
|
14.9%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.1% · Q3 2.3% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.5%
0.1 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.6%
1.6 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 31.4% |
22.2%
9.2 pts worse
|
19.8%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.4% · Q2 25.3% · Q3 23.7% · Q4 29.8% · 4Q avg 31.4% |
| Percentage of long-stay residents with pressure ulcers | 10.6% |
5.2%
5.4 pts worse
|
5.1%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 11.1% · Q3 12.5% · Q4 15.0% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.3% |
74.6%
18.7 pts better
|
81.7%
11.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.8% · Q2 93.5% · Q3 97.7% · Q4 94.1% · 4Q avg 93.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.3% |
11.7%
4.4 pts better
|
12.0%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.3% · Observed 6.8% · Expected 10.3% · 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 0.0% · Q2 0.3% · Q3 1.0% · Q4 2.2% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.6% |
73.6%
21 pts better
|
79.7%
14.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.6% |
22.0%
0.4 pts better
|
23.9%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.6% · Observed 21.2% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-03-19 · Fire 2021-03-19
8 health deficiencies
Top issue: Resident Rights (4 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2018-06-14 · Fire 2018-06-14
5 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2021-03-19
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 2021-04-30
D · Potential for more than minimal harm
2021-03-19
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2021-04-30
D · Potential for more than minimal harm
2021-03-19
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-04-30
D · Potential for more than minimal harm
2021-03-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-04-30
D · Potential for more than minimal harm
2021-03-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-04-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2023-06-29
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.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-06-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-06-29
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-06-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-06-29
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 2023-08-01
E · Potential for more than minimal harm
2023-06-29
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-06-29
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-29
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 2023-08-01
D · Potential for more than minimal harm
2023-06-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-29
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-08-01
E · Potential for more than minimal harm
2021-03-19
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 2021-04-14
E · Potential for more than minimal harm
2021-03-19
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 2021-04-14
D · Potential for more than minimal harm
2021-03-19
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 2021-04-14
D · Potential for more than minimal harm
2021-03-19
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.
Corrected 2021-04-14
D · Potential for more than minimal harm
2021-03-19
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2021-04-14
D · Potential for more than minimal harm
2021-03-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-04-14
D · Potential for more than minimal harm
2021-03-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-04-14
D · Potential for more than minimal harm
2021-03-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-04-14
D · Potential for more than minimal harm
2018-06-14
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2018-07-05
D · Potential for more than minimal harm
2018-06-14
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2018-07-05
D · Potential for more than minimal harm
2018-06-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2018-07-05
D · Potential for more than minimal harm
2018-06-14
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 2018-07-05
D · Potential for more than minimal harm
2018-06-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-07-05
Penalties and ownership
What sits behind the stars
Ownership
Burke Holdings I LLC
5% Or Greater Direct Ownership Interest · Organization
Charles 1994 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Chesapeake East LLC
5% Or Greater Indirect Ownership Interest · Organization
Edward 1998 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Ek 2005 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Fay 2014 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Fay 2014 LLC
5% Or Greater Indirect Ownership Interest · Organization
Kee, Terrence
Corporate Director · Individual
Kee, Terrence
W-2 Managing Employee · Individual
Ll 2013 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Mms 2008 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Mzr East LLC
5% Or Greater Indirect Ownership Interest · Organization
Rylbss East Manager LLC
Operational/Managerial Control · Organization
Saul 2012 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Silverstone East LLC
5% Or Greater Indirect Ownership Interest · Organization
Sol 2000 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Sol 2000 LLC
5% Or Greater Indirect Ownership Interest · Organization
Stevens 3920 & Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Stevens 3920 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Stevens 3920 LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
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Greenspring Village
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#2
Fairfax Rehabilitation And Nursing Center
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3-star overall rating with 2-star inspections with $28,534 in total fines with 22 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
August Healthcare At Leewood
Annandale, VA
3-star overall rating with 2-star inspections with 19 recent health deficiencies
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