Cycle 1
Health 2023-07-12 · Fire 2023-07-12
11 health deficiencies
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Arlington, VA
Regency Care Of Arlington, LLC
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1785 South Hayes Street, Arlington, VA
(703) 920-5700
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
240
Certified beds
Average residents
167
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Regency Care
Operator or chain grouping
Approved since
1978-10-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 3 overall / 2 health / 3 staffing / 3 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
0.58
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.88
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.43
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.81
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,663
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.45
Composite VBP score used to determine payment impact.
Payment multiplier
1.0022
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.90
Baseline 19.88% · Performance 18.70% · Measure score 5.90 · Achievement 5.90 · Improvement 3.65
Healthcare-associated infections
5.18
Baseline 6.91% · Performance 6.29% · Measure score 5.18 · Achievement 5.18 · Improvement 2.74
Total nurse turnover
6.10
Performance 38.73% · Measure score 6.10 · Achievement 6.10 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.19
Baseline 3.30 hours · Performance 3.70 hours · Measure score 2.19 · Achievement 2.19 · Improvement 1.12
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.5% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 121 · Observed rate 21.49% · Lower 95% interval 9.63% |
| Discharge to community | 47.42% |
50.57%
3.1 pts worse
|
No Different than the National Rate · Eligible stays 134 · Observed rate 27.61% · Lower 95% interval 36.31% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 96.81% |
95.27%
1.5 pts better
|
Numerator 91 · Denominator 94 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 94 |
| Discharge self-care score | 43.14% |
53.69%
10.5 pts worse
|
Numerator 22 · Denominator 51 |
| Discharge mobility score | 37.25% |
50.94%
13.7 pts worse
|
Numerator 19 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 7.45% |
2.29%
5.2 pts worse
|
Numerator 7 · Denominator 94 · Adjusted rate 5.05% |
| Healthcare-associated infections requiring hospitalization | 6.29% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 7.02% · Lower 95% interval 3.43% |
| Staff COVID-19 vaccination coverage | 14.9% |
8.2%
6.7 pts better
|
Numerator 31 · Denominator 208 |
| Staff flu vaccination coverage | 39.33% |
42%
2.7 pts worse
|
Numerator 94 · Denominator 239 |
| Discharge function score | 35.29% |
56.45%
21.2 pts worse
|
Numerator 18 · Denominator 51 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 37 · Denominator 37 |
| Transfer of health information to patient | 92.31% |
96.28%
4 pts worse
|
Numerator 24 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 11.76% |
25.2%
13.4 pts worse
|
Numerator 6 · Denominator 51 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.5
0.7 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.2 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.4
0.5 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 63.0% |
91.2%
28.2 pts worse
|
93.4%
30.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 56.0% · Q2 62.6% · Q3 67.1% · Q4 66.2% · 4Q avg 63.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 78.5% |
94.0%
15.5 pts worse
|
95.5%
17 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 78.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.6%
1.6 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.0% · Q3 1.3% · Q4 1.4% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.2% |
15.7%
15.5 pts better
|
11.4%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
5.7%
1 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 6.4% · Q3 3.4% · Q4 1.4% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.2% |
20.2%
8 pts better
|
19.6%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 11.3% · Q3 12.8% · Q4 13.5% · 4Q avg 12.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.5% |
15.0%
1.5 pts better
|
16.7%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 16.8% · Q3 13.1% · Q4 9.1% · 4Q avg 13.5% · 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 | 27.3% |
17.5%
9.8 pts worse
|
16.3%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 49.6% · Q2 29.0% · Q3 23.1% · Q4 6.8% · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.3% |
15.7%
15.6 pts worse
|
14.9%
16.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.6% · Q2 36.8% · Q3 30.1% · Q4 16.9% · 4Q avg 31.3% · 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 0.6% · Q3 0.5% · Q4 0.6% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.6%
0.6 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 2.7% · Q4 0.7% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.4% |
22.2%
4.2 pts worse
|
19.8%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 23.6% · Q3 32.0% · Q4 25.3% · 4Q avg 26.4% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
5.2%
2.7 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 7.9% · Q3 8.1% · Q4 5.1% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 17.4% |
74.6%
57.2 pts worse
|
81.7%
64.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 13.0% · Q3 20.5% · Q4 20.0% · 4Q avg 17.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.2% |
11.7%
4.5 pts better
|
12.0%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.2% · Observed 9.3% · Expected 14.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.2%
0.6 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.0% · Q3 1.3% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 29.4% |
73.6%
44.2 pts worse
|
79.7%
50.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 29.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.7% |
22.0%
4.3 pts better
|
23.9%
6.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.7% · Observed 25.3% · Expected 34.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-31 · Fire 2022-08-31
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
21 fire-safety deficiencies
Top issue: Egress (7 deficiencies)
Cycle 3
Health 2020-02-27 · Fire 2020-02-27
11 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-07-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-11-07
D · Potential for more than minimal harm
2023-07-12
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-11-07
E · Potential for more than minimal harm
2022-08-31
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-03-06
E · Potential for more than minimal harm
2022-08-31
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-03-06
E · Potential for more than minimal harm
2022-08-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-06
D · Potential for more than minimal harm
2022-08-31
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-03-06
D · Potential for more than minimal harm
2022-08-31
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 2023-03-06
D · Potential for more than minimal harm
2022-08-31
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 2023-03-06
D · Potential for more than minimal harm
2022-08-31
K233 · Egress Deficiencies
Fire Safety
Install resident room doors of proper design and width.
Corrected 2023-03-06
D · Potential for more than minimal harm
2022-08-31
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-03-06
D · Potential for more than minimal harm
2022-08-31
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-06
D · Potential for more than minimal harm
2022-08-31
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-03-06
D · Potential for more than minimal harm
2022-08-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-06
D · Potential for more than minimal harm
2022-08-31
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-03-06
D · Potential for more than minimal harm
2022-08-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-06
D · Potential for more than minimal harm
2022-08-31
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-03-06
D · Potential for more than minimal harm
2022-08-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-06
D · Potential for more than minimal harm
2022-08-31
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2023-03-06
D · Potential for more than minimal harm
2022-08-31
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-03-06
D · Potential for more than minimal harm
2022-08-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-06
D · Potential for more than minimal harm
2022-08-31
K771 · Miscellaneous Deficiencies
Fire Safety
Ensure that smoke control systems are tested and documented in accordance with established engineering principles.
Corrected 2023-03-06
D · Potential for more than minimal harm
2022-08-31
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-03-06
D · Potential for more than minimal harm
2022-08-31
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-03-06
D · Potential for more than minimal harm
2020-02-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-03-11
D · Potential for more than minimal harm
2020-02-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-03-11
D · Potential for more than minimal harm
2020-02-27
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2021-03-11
D · Potential for more than minimal harm
2020-02-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-03-11
D · Potential for more than minimal harm
2020-02-27
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2021-03-11
Inspection history
Recent health citations
E · Potential for more than minimal harm
2023-07-12
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 2023-08-04
E · Potential for more than minimal harm
2023-07-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-04
D · Potential for more than minimal harm
2023-07-12
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 2023-08-04
D · Potential for more than minimal harm
2023-07-12
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-04
D · Potential for more than minimal harm
2023-07-12
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 2023-08-04
D · Potential for more than minimal harm
2023-07-12
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 2023-08-04
D · Potential for more than minimal harm
2023-07-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-04
D · Potential for more than minimal harm
2023-07-12
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 2023-08-04
D · Potential for more than minimal harm
2023-07-12
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-08-04
D · Potential for more than minimal harm
2023-07-12
F693 · Quality of Life and Care Deficiencies
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 2023-08-04
D · Potential for more than minimal harm
2023-07-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-04
F · Potential for more than minimal harm
2022-08-31
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-09-19
F · Potential for more than minimal harm
2022-08-31
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2022-09-19
E · Potential for more than minimal harm
2022-08-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-09-19
E · Potential for more than minimal harm
2022-08-31
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 2022-09-19
D · Potential for more than minimal harm
2022-08-31
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 2022-09-19
E · Potential for more than minimal harm
2020-02-27
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 2020-03-19
E · Potential for more than minimal harm
2020-02-27
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 2020-03-19
E · Potential for more than minimal harm
2020-02-27
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 2020-03-19
E · Potential for more than minimal harm
2020-02-27
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2020-03-19
E · Potential for more than minimal harm
2020-02-27
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 2020-03-19
D · Potential for more than minimal harm
2020-02-27
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 2020-03-19
D · Potential for more than minimal harm
2020-02-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-03-19
D · Potential for more than minimal harm
2020-02-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-03-19
D · Potential for more than minimal harm
2020-02-27
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 2020-03-19
D · Potential for more than minimal harm
2020-02-27
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2020-03-19
D · Potential for more than minimal harm
2020-02-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-19
Penalties and ownership
What sits behind the stars
Ownership
Womack, Steven
5% Or Greater Direct Ownership Interest · Individual
Munro, Jason
Operational/Managerial Control · Individual
Womack, Steven
Operational/Managerial Control · Individual
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#3
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