Cycle 1
Health 2023-05-05 · Fire 2023-05-05
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Alexandria, VA
Woodbine Rehabilitation & Healthcare Center
5-star overall rating with 4-star inspections with 2 recent health deficiencies
2729 King St, Alexandria, VA
(703) 836-8838
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
307
Certified beds
Average residents
283
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Marquis Health Services
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
81 facilities
Chain averages 3 overall / 3 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
1.01
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.96
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
2.04
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.54
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.64
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
2.66
CMS adjusted total nurse staffing hours
Case-mix index
2.03
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,881
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9828
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.47
Baseline 22.09% · Performance 21.59% · Measure score 0.47 · Achievement 0 · Improvement 0.47
Healthcare-associated infections
0
Baseline 9.30% · Performance 10.78% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
8.40
Baseline 35.54% · Performance 29.34% · Measure score 8.40 · Achievement 8.40 · Improvement 5.3
Adjusted total nurse staffing
0
Baseline 2.96 hours · Performance 2.92 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.28% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 464 · Observed rate 8.62% · Lower 95% interval 7.36% |
| Discharge to community | 54.54% |
50.57%
4 pts better
|
No Different than the National Rate · Eligible stays 552 · Observed rate 46.2% · Lower 95% interval 50.08% |
| Medicare spending per beneficiary | 1.23 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 95.44% |
95.27%
0.2 pts better
|
Numerator 398 · Denominator 417 |
| Falls with major injury | 0.48% |
0.77%
0.3 pts better
|
Numerator 2 · Denominator 417 |
| Discharge self-care score | 53.68% |
53.69%
About the same
|
Numerator 51 · Denominator 95 |
| Discharge mobility score | 63.16% |
50.94%
12.2 pts better
|
Numerator 60 · Denominator 95 |
| Pressure ulcers or injuries, new or worsened | 0.24% |
2.29%
2 pts better
|
Numerator 1 · Denominator 417 · Adjusted rate 0.19% |
| Healthcare-associated infections requiring hospitalization | 10.78% |
7.12%
3.7 pts worse
|
Worse than the National Rate · Eligible stays 349 · Observed rate 12.89% · Lower 95% interval 8.12% |
| Staff COVID-19 vaccination coverage | 3.13% |
8.2%
5.1 pts worse
|
Numerator 12 · Denominator 383 |
| Staff flu vaccination coverage | 39.2% |
42%
2.8 pts worse
|
Numerator 147 · Denominator 375 |
| Discharge function score | 68.42% |
56.45%
12 pts better
|
Numerator 65 · Denominator 95 |
| Transfer of health information to provider | 95.71% |
95.95%
0.2 pts worse
|
Numerator 134 · Denominator 140 |
| Transfer of health information to patient | 84.44% |
96.28%
11.8 pts worse
|
Numerator 190 · Denominator 225 |
| Resident COVID-19 vaccinations up to date | 45.97% |
25.2%
20.8 pts better
|
Numerator 97 · Denominator 211 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.5
0.2 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.3 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.4
0.4 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.1 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.5% |
91.2%
3.3 pts better
|
93.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 91.6% · Q2 94.9% · Q3 95.2% · Q4 96.3% · 4Q avg 94.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
94.0%
5.1 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.8% |
3.6%
2.8 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 1.4% · Q3 1.0% · Q4 0.5% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 51.8% |
15.7%
36.1 pts worse
|
11.4%
40.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 37.6% · Q3 79.1% · Q4 79.7% · 4Q avg 51.8% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
5.7%
0.4 pts worse
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 8.3% · Q3 5.6% · Q4 4.5% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.4% |
20.2%
9.8 pts better
|
19.6%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 11.1% · Q3 10.6% · Q4 10.1% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.9% |
15.0%
2.9 pts worse
|
16.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 18.0% · Q3 17.1% · Q4 17.4% · 4Q avg 17.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.9% |
0.2%
0.7 pts worse
|
0.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.5% · Q3 1.0% · Q4 1.9% · 4Q avg 0.9% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.2% |
17.5%
12.3 pts better
|
16.3%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 9.3% · Q3 4.3% · Q4 4.4% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.3% |
15.7%
11.4 pts better
|
14.9%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 4.4% · Q3 10.6% · Q4 0.7% · 4Q avg 4.3% · 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 | 0.1% |
1.6%
1.5 pts better
|
1.7%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.6% |
22.2%
8.6 pts better
|
19.8%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.6% · Q2 12.9% · Q3 10.8% · Q4 14.0% · 4Q avg 13.6% |
| Percentage of long-stay residents with pressure ulcers | 20.3% |
5.2%
15.1 pts worse
|
5.1%
15.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 22.2% · Q3 19.4% · Q4 19.6% · 4Q avg 20.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.4% |
74.6%
7.8 pts better
|
81.7%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 78.8% · Q2 80.7% · Q3 84.3% · Q4 86.0% · 4Q avg 82.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.2% |
11.7%
0.5 pts better
|
12.0%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 10.6% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.2%
0.6 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.4% · Q3 0.4% · Q4 0.8% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.7% |
73.6%
11.1 pts better
|
79.7%
5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.0% |
22.0%
2 pts better
|
23.9%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 20.9% · Expected 24.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-02-24 · Fire 2022-02-24
17 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-04-23 · Fire 2021-04-23
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-05-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-11
D · Potential for more than minimal harm
2023-05-05
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-07-11
E · Potential for more than minimal harm
2022-02-24
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 2022-03-30
E · Potential for more than minimal harm
2022-02-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-03-30
E · Potential for more than minimal harm
2022-02-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-03-30
E · Potential for more than minimal harm
2022-02-24
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 2022-03-30
E · Potential for more than minimal harm
2022-02-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-30
D · Potential for more than minimal harm
2022-02-24
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-03-30
D · Potential for more than minimal harm
2022-02-24
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 2022-03-30
D · Potential for more than minimal harm
2022-02-24
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 2022-03-30
D · Potential for more than minimal harm
2022-02-24
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2022-03-30
D · Potential for more than minimal harm
2022-02-24
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 2022-03-30
D · Potential for more than minimal harm
2022-02-24
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 2022-03-30
D · Potential for more than minimal harm
2022-02-24
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-03-30
D · Potential for more than minimal harm
2022-02-24
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 2022-03-30
D · Potential for more than minimal harm
2022-02-24
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 2022-03-30
D · Potential for more than minimal harm
2022-02-24
F772 · Administration Deficiencies
Health
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
Corrected 2022-03-30
D · Potential for more than minimal harm
2022-02-24
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 2022-03-30
D · Potential for more than minimal harm
2022-02-24
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2022-03-30
D · Potential for more than minimal harm
2021-04-23
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 2021-05-30
Penalties and ownership
What sits behind the stars
Ownership
Quinto Delta LLC
5% Or Greater Direct Ownership Interest · Organization
Ukr Consulting LLC
5% Or Greater Direct Ownership Interest · Organization
Kohn Fam Tr Gst Exempt Uad 3-25-13
5% Or Greater Indirect Ownership Interest · Organization
M&T Bank
5% Or Greater Security Interest · Organization
Marquis Limited LLC
Operational/Managerial Control · Organization
Nfr 2020 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Posen, Mindee
Corporate Officer · Individual
Reliant Pro Rehab LLC
Operational/Managerial Control · Organization
Rsbrmk Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Shaw, Donna
Operational/Managerial Control · Individual
Shaw, Donna
Corporate Director · Individual
Silis, Manny
Operational/Managerial Control · Individual
Sk 2013 Delta Trust
5% Or Greater Indirect Ownership Interest · Organization
Skilled Venture LLC
5% Or Greater Direct Ownership Interest · Organization
Tryko Delta Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Uak 2020 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Yr 2013 Delta Tr Ua 03252013
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Alexandria Rehabilitation And Healthcare Center
Alexandria, VA
3-star overall rating with 2-star inspections with 11 recent health deficiencies
#2
Goodwin House Alexandria
Alexandria, VA
5-star overall rating with 4-star inspections with 4 recent health deficiencies
#3
Regency Care Of Arlington, LLC
Arlington, VA
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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