Cycle 1
Health 2024-08-21 · Fire 2024-08-21
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.
Falls Church, VA
Goodwin House Bailey's Crossroads
5-star overall rating with 4-star inspections with 8 recent health deficiencies
3440 S Jefferson Street, Falls Church, VA
(703) 578-7261
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
73
Certified beds
Average residents
67
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1987-11-04
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
1.63
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
3.19
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
5.51
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
2.31
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
5.09
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
1.30
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.64
CMS adjusted RN staffing hours
Adjusted total hours
5.56
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
20%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
50
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
92.18
Composite VBP score used to determine payment impact.
Payment multiplier
1.0274
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.19
Baseline 21.99% · Performance 17.17% · Measure score 9.19 · Achievement 9.19 · Improvement 9
Healthcare-associated infections
7.68
Baseline 5.58% · Performance 5.54% · Measure score 7.68 · Achievement 7.68 · Improvement 0.23
Total nurse turnover
10
Baseline 32.58% · Performance 21.18% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
10
Baseline 5.36 hours · Performance 5.79 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.85% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 126 · Observed rate 7.14% · Lower 95% interval 7.34% |
| Discharge to community | 50.99% |
50.57%
0.4 pts better
|
No Different than the National Rate · Eligible stays 109 · Observed rate 48.62% · Lower 95% interval 42.88% |
| Medicare spending per beneficiary | 0.64 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 93.85% |
95.27%
1.4 pts worse
|
Numerator 61 · Denominator 65 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 65 |
| Discharge self-care score | 31.15% |
53.69%
22.5 pts worse
|
Numerator 19 · Denominator 61 |
| Discharge mobility score | 26.23% |
50.94%
24.7 pts worse
|
Numerator 16 · Denominator 61 |
| Pressure ulcers or injuries, new or worsened | 1.54% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 65 · Adjusted rate 1.23% |
| Healthcare-associated infections requiring hospitalization | 5.54% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 0% · Lower 95% interval 2.6% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 162 |
| Staff flu vaccination coverage | 56.64% |
42%
14.6 pts better
|
Numerator 81 · Denominator 143 |
| Discharge function score | 36.07% |
56.45%
20.4 pts worse
|
Numerator 22 · Denominator 61 |
| Transfer of health information to provider | 79.17% |
95.95%
16.8 pts worse
|
Numerator 19 · Denominator 24 |
| 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 | 80% |
25.2%
54.8 pts better
|
Numerator 28 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.5
0.9 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.9 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.4
0.3 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
91.2%
8 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.2% |
| 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 | 3.4% |
3.6%
0.2 pts better
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.4% · Q3 3.3% · Q4 5.4% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.4% |
15.7%
13.3 pts better
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 4.1% · Q3 1.8% · Q4 2.0% · 4Q avg 2.4% |
| Percentage of long-stay residents who lose too much weight | 5.5% |
5.7%
0.2 pts better
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.1% · Q3 2.0% · Q4 12.5% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.7% |
20.2%
4.5 pts better
|
19.6%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 15.7% · Q3 16.7% · Q4 18.4% · 4Q avg 15.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.8% |
15.0%
4.2 pts better
|
16.7%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 10.0% · Q3 9.8% · Q4 7.0% · 4Q avg 10.8% · 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 | 19.8% |
17.5%
2.3 pts worse
|
16.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q4 21.9% · 4Q avg 19.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.5% |
15.7%
6.8 pts worse
|
14.9%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 11.1% · Q3 29.3% · Q4 21.4% · 4Q avg 22.5% · 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 0.0% · Q3 1.7% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
1.6%
1.5 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 1.7% · Q4 9.1% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.9% |
22.2%
4.3 pts better
|
19.8%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 9.9% · Q3 15.7% · Q4 28.9% · 4Q avg 17.9% |
| Percentage of long-stay residents with pressure ulcers | 1.4% |
5.2%
3.8 pts better
|
5.1%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.5% · Q3 1.2% · Q4 1.1% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.0% |
74.6%
19.4 pts better
|
81.7%
12.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 98.1% · Q3 92.5% · Q4 89.1% · 4Q avg 94.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.3% |
11.7%
0.6 pts worse
|
12.0%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.3% · Observed 10.8% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.2%
0.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.5% |
73.6%
22.9 pts better
|
79.7%
16.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.4% |
22.0%
0.4 pts worse
|
23.9%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 18.5% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-26 · Fire 2023-04-26
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2021-11-04 · Fire 2021-11-04
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
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
2023-04-26
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 2023-06-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-08-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-04
E · Potential for more than minimal harm
2024-08-21
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 2024-10-04
D · Potential for more than minimal harm
2024-08-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-08-21
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 2024-10-04
D · Potential for more than minimal harm
2024-08-21
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 2024-10-04
D · Potential for more than minimal harm
2024-08-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-08-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-08-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-10-04
E · Potential for more than minimal harm
2023-04-26
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 2023-05-26
D · Potential for more than minimal harm
2021-11-04
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-12-17
D · Potential for more than minimal harm
2021-11-04
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 2021-12-17
D · Potential for more than minimal harm
2021-11-04
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 2021-12-17
D · Potential for more than minimal harm
2021-11-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-12-17
D · Potential for more than minimal harm
2021-11-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-12-17
D · Potential for more than minimal harm
2021-11-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-12-17
D · Potential for more than minimal harm
2021-11-04
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2021-12-17
Penalties and ownership
What sits behind the stars
Ownership
Liebreich, Robert
5% Or Greater Indirect Ownership Interest · Individual
Bernateau, Sherretta
Corporate Officer · Individual
Bernateau, Sherretta
W-2 Managing Employee · Individual
Calloway, Donald
Corporate Director · Individual
Calloway, Donald
Corporate Officer · Individual
Carwile, Justin
Corporate Director · Individual
Choi, Phoebe
Corporate Officer · Individual
Choi, Phoebe
W-2 Managing Employee · Individual
Clark, Cyrillene
Corporate Director · Individual
Clarke, David
Corporate Director · Individual
Forbes, Deborah
Corporate Director · Individual
Hanisian, Holly
Corporate Officer · Individual
Hansen, Janet
Corporate Director · Individual
Hix, Mary
Corporate Director · Individual
Hix, Mary
Corporate Officer · Individual
Hudson, Melinda
Corporate Director · Individual
Hudson, Melinda
Corporate Officer · Individual
Kumar, Chandra
Corporate Officer · Individual
Randolph, Nancy
Corporate Director · Individual
Regnell, Tom
Corporate Director · Individual
Siegel, Andrew
Corporate Officer · Individual
Siegel, Andrew
W-2 Managing Employee · Individual
Smith, Charles
Corporate Director · Individual
Smith, Timothy
Corporate Officer · Individual
Smith, Timothy
W-2 Managing Employee · Individual
West, Thomas
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Carlin Springs Health & Rehabilitation
Arlington, VA
1-star overall rating with 1-star inspections with 19 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Goodwin House Alexandria
Alexandria, VA
5-star overall rating with 4-star inspections with 4 recent health deficiencies
#3
The Jefferson
Arlington, VA
4-star overall rating with 3-star inspections with 16 recent health deficiencies
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