Trends-SNF

LeadingAge Nursing Home Trend Report

SNF Information

This section provides details for the selected organization including trends for certified beds and total census.

Information for SNF, Fairfax County, VA as of 2023-06-01

State	VA
County	Fairfax
Urban Rural Designation	Urban
Ownership	Non Profit - Corporation
Certification	Medicare and Medicaid
In Hospital	N
CCRC Facility	Yes
Special Focus Facility	Not a SFF
Changed Ownership in Last 12 Months	No
Resident Family Council	Resident
Sprinkler Status	Yes

Bed & Resident Counts

Occupancy Percentage

5 Star Ratings

An overall 5 Star rating is assigned to a provider based on the results of each of three domains: health inspection (survey), staffing, and quality measures. The following time series analyses are provided for each of the 5 Star ratings comparing provider to county, state, and national.

5 Star Ratings - Overall

5 Star Ratings - Survey

5 Star Ratings - Staffing

5 Star Ratings - Quality

5 Star Ratings - Quality Rating - Long Stay

5 Star Ratings - Quality Rating - Short Stay

Health Inspection

The total weighted all cycles score is based on the number, scope, and severity of deficiencies identified during the three most recent annual inspection surveys plus findings from the most recent 36 months of complaint investigations and focused infection control surveys all weighted by scope and severity. The total weighted all cycles score for the three surveys (plus complaints and focused infection control deficiencies if any) is what determines the number of stars assigned for the health inspection 5 star rating, based on the cut points at the time of the survey. A lower score is better. The following time series analysis displays the total weighted all cycles health survey score for the provider compared to the county and state scores. The table below shows the count of health deficiencies by scope and severity for each of the 3 most recent insection cycles.

Survey - Total Weighted All Cycles Score

Scope and Severity of Health Deficiencies

Severity	Cycle	Scope
Severity	Cycle	Isolated		Pattern		Widespread
Immediate jeopardy to resident health or safety	1	J	0	K	0	L	0
	2		0		0		0
	3		0		0		0
Actual harm that is not immediate jeopardy	1	G	0	H	0	I	0
	2		0		0		0
	3		0		0		0
No actual harm with potential for more than minimal harm that is not immediate jeopardy	1	D	7	E	0	F	0
	2		2		1		0
	3		5		0		1
No actual harm with potential for minimal harm	1	A	0	B	0	C	0
	2		0		0		0
	3		0		0		0

Adjusted Staff Hours

Adjusted Staff Hours per resident day is case mix adjusted based on the RUG IV groups. The following time series analyses display the case mix adjusted hours for CNA, LPN, RN, Total Nurses (RN + LPN + nurse aide), and weekend Total Nurse staffing while comparing the provider to county, state, and national.

Staffing - CNA

Staffing - LPN

Staffing - RN

Staffing - Total

Adjusted Weekend Staff Hours - Total Nurse

Weekend Staff Hours (not case mix adjusted)

The following time series analyses display the weekend reported hours per resident day for RN and Total Nurses (RN + LPN + nurse aide). Due to these measures not being case mix adjusted, there is no comparison with county, state, or national.

Non-Adjusted Weekend Staff Hours - RN

Non-Adjusted Weekend Staff Hours - Total Nurse

Staff Turnover

The following time series analyses display the turnover percentages for RNs & Total Nurses (RN + LPN + nurse aide) and the turnover counts for Nursing Home Administrators while comparing the provider to county, state, and national.

Staff Turnover - RN

Staff Turnover - Total Nurse

Staff Turnover - Administrator

Quality Measures

The Quality Measure 5 Star rating is based on 15 of the QMs currently posted on Care Compare. The following time series analyses displays each of the quality measures and compares the provider rates to county, state, and national rates. Colored labels indicate whether the measure is a long-stay or short-stay measure, if it is MDS-based or claims-based, whether it is used in the Skilled Nursing Facility Quality Reporting Program (QRP), whether a higher rate is better, and if the measure is used in the 5 Star ratings.

LS_ADLs Long Stay MDS 5 Star Measure

Percentage of long-stay residents whose need for help with daily activities has increased

LS_AntiAnxiety Long Stay MDS

Percentage of long-stay residents who received an antianxiety or hypnotic medication

LS_AntiPsych Long Stay MDS 5 Star Measure

Percentage of long-stay residents who received an antipsychotic medication

LS_Catheter Long Stay MDS 5 Star Measure

Percentage of long-stay residents with a catheter inserted and left in their bladder

LS_Depression Long Stay MDS

Percentage of long-stay residents who have depressive symptoms

LS_EDvisitsPer1000Days Long Stay Claims 5 Star Measure

Number of outpatient emergency department visits per 1000 long-stay resident days

LS_Falls Long Stay MDS 5 Star Measure

Percentage of long-stay residents experiencing one or more falls with major injury

LS_Flu Long Stay MDS Higher is Better

Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine

LS_HighRiskPU Long Stay MDS 5 Star Measure

Percentage of high risk long-stay residents with pressure ulcers

LS_HospPer1000Days Long Stay Claims 5 Star Measure

Number of hospitalizations per 1000 long-stay resident days

LS_Incontinence Long Stay MDS

Percentage of low risk long-stay residents who lose control of their bowels or bladder

LS_Locomotion Long Stay MDS 5 Star Measure

Percentage of long-stay residents whose ability to move independently worsened

LS_Pneumo Long Stay MDS Higher is Better

Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine

LS_Restraints Long Stay MDS

Percentage of long-stay residents who were physically restrained

LS_UTI Long Stay MDS 5 Star Measure

Percentage of long-stay residents with a urinary tract infection

LS_WeightLoss Long Stay MDS

Percentage of long-stay residents who lose too much weight

QRP_ChangeMove Short Stay QRP

Change in residents’ ability to move around

QRP_ChangeSelfCare Short Stay QRP

Change in residents’ ability to care for themselves

QRP_FallsMajorInjury Short Stay QRP

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay

QRP_FxnAbilityGoalsInPlan Short Stay QRP Higher is Better

Percentage of SNF residents whose functional abilities were assessed and functional goals were included in their treatment plan

QRP_HospitalReadmission Short Stay QRP

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF

QRP_MedsManaged Short Stay QRP Higher is Better

Percentage of SNF residents whose medications were reviewed and who received follow-up care when medication issues were identified

QRP_MoveAtDischarge Short Stay QRP Higher is Better

Percentage of residents who are at or above an expected ability to move around at discharge

QRP_MSPB Short Stay QRP

The Medicare Spending Per Beneficiary (MSPB) for residents in SNFs

QRP_SelfCareAtDischarge Short Stay QRP Higher is Better

Percentage of residents who are at or above an expected ability to care for themselves at discharge

QRP_SS_PU Short Stay QRP 5 Star Measure

Percentage of residents with pressure ulcers/pressure injuries that are new or worsened

QRP_SS_ReturnToComm Short Stay QRP 5 Star Measure Higher is Better

Rate of successful return to home and community from a SNF

SS_AntiPsych Short Stay MDS 5 Star Measure

Percentage of short-stay residents who newly received an antipsychotic medication

SS_EDvisit Short Stay Claims 5 Star Measure

Percentage of short-stay residents who had an outpatient emergency department visit

SS_Flu Short Stay MDS Higher is Better

Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine

SS_ImpTrLocWk Short Stay MDS 5 Star Measure Higher is Better

Percentage of short-stay residents who made improvements in function

SS_Pneumo Short Stay MDS Higher is Better

Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine

SS_Rehosp Short Stay Claims 5 Star Measure

Percentage of short-stay residents who were rehospitalized after a nursing home admission