Lake Ridge, VA
5-star overall rating with 4-star inspections with $12,740 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
12185 Clipper Drive, Lake Ridge, VA
(703) 643-9017
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
60
Certified beds
Average residents
45
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ingleside Engaged Living
Operator or chain grouping
Approved since
1993-07-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
3 facilities
Chain averages 5 overall / 4 health / 5 staffing / 5 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
RN hours / resident day
1.26
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.00
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.63
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
4.89
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
2.26
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.41
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
1.08
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.26
CMS adjusted RN staffing hours
Adjusted total hours
4.91
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
1,573
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.56
Composite VBP score used to determine payment impact.
Payment multiplier
1.0106
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
6.09
Baseline 24.29% · Performance 19.50% · Measure score 6.09 · Achievement 4.16 · Improvement 6.09
Healthcare-associated infections
2.63
Baseline 7.59% · Performance 7.05% · Measure score 2.63 · Achievement 2.63 · Improvement 1.59
Total nurse turnover
6.52
Baseline 54.24% · Performance 37.04% · Measure score 6.52 · Achievement 6.52 · Improvement 5.35
Adjusted total nurse staffing
6.99
Baseline 4.85 hours · Performance 5.07 hours · Measure score 6.99 · Achievement 6.99 · Improvement 1.84
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.03% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 272 · Observed rate 12.87% · Lower 95% interval 9.28% |
| Discharge to community | 63.02% |
50.57%
12.5 pts better
|
Better than the National Rate · Eligible stays 294 · Observed rate 55.44% · Lower 95% interval 57.09% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.01% |
95.27%
2.7 pts better
|
Numerator 148 · Denominator 151 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 151 |
| Discharge self-care score | 52.59% |
53.69%
1.1 pts worse
|
Numerator 61 · Denominator 116 |
| Discharge mobility score | 59.48% |
50.94%
8.5 pts better
|
Numerator 69 · Denominator 116 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 151 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.05% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 144 · Observed rate 6.25% · Lower 95% interval 4.14% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 92.77% |
42%
50.8 pts better
|
Numerator 231 · Denominator 249 |
| Discharge function score | 55.17% |
56.45%
1.3 pts worse
|
Numerator 64 · Denominator 116 |
| Transfer of health information to provider | 96.97% |
95.95%
1 pts better
|
Numerator 32 · Denominator 33 |
| Transfer of health information to patient | 99.01% |
96.28%
2.7 pts better
|
Numerator 100 · Denominator 101 |
| Resident COVID-19 vaccinations up to date | 62.67% |
25.2%
37.5 pts better
|
Numerator 47 · Denominator 75 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
1.5
1.1 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 3.4 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
1.4
1.8 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.8 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
91.2%
0.5 pts better
|
93.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 93.1% · Q3 88.9% · Q4 84.6% · 4Q avg 91.7% |
| 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 | 4.6% |
3.6%
1 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 10.3% · Q3 3.7% · Q4 0.0% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
15.7%
13.7 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 8.7% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
5.7%
1.5 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.0% · Q3 4.3% · Q4 4.2% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.2% |
20.2%
1 pts worse
|
19.6%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 26.9% · Q3 16.7% · Q4 16.7% · 4Q avg 21.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.5% |
15.0%
5.5 pts better
|
16.7%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.5% · 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 | 46.5% |
17.5%
29 pts worse
|
16.3%
30.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 46.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.9% |
15.7%
8.2 pts worse
|
14.9%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 20.0% · 4Q avg 23.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.5%
0.7 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
1.6%
0.3 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 3.8% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.9% |
22.2%
2.3 pts better
|
19.8%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 12.8% · Q3 25.5% · Q4 30.1% · 4Q avg 19.9% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
5.2%
3.7 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 3.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.0% |
74.6%
3.4 pts better
|
81.7%
3.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 86.3% · Q2 88.2% · Q3 78.3% · Q4 60.7% · 4Q avg 78.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.5% |
11.7%
8.2 pts better
|
12.0%
8.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.5% · Observed 3.2% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.2%
0.1 pts worse
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.3% · Q3 1.2% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.9% |
73.6%
19.3 pts better
|
79.7%
13.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
22.0%
2.8 pts worse
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 23.2% · Expected 22.3% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Pharmacy Service (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Have proper power supply for life support equipment.
Corrected 2022-08-12
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-08-12
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-08-14
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-08-14
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-08-14
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-08-14
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-08-14
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-08-14
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-08-14
Inspection history
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-07-31
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-07-31
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-07-31
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-06-28
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-06-28
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 2019-06-28
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-06-28
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-28
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2019-06-28
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-06-28
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 2019-06-28
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-06-28
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 2019-06-28
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2019-06-28
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-06-28
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-06-28
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-06-28
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-06-28
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 2019-06-28
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2019-06-28
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2018-03-08
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2018-03-08
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2018-03-08
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-03-08
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-03-08
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2018-03-08
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2018-03-08
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 2018-03-08
Penalties and ownership
Fine · fine $12,740
Fine
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Nearby options
Woodbridge, VA
3-star overall rating with 2-star inspections with $12,834 in total fines with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Fort Belvoir, VA
5-star overall rating with 5-star inspections with 2 recent health deficiencies
Burke, VA
3-star overall rating with 3-star inspections with 11 recent health deficiencies
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