Cycle 1
Health 2023-06-07 · Fire 2023-06-07
12 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fredericksburg, VA
Carriage Hill Health & Rehab Center
3-star overall rating with 3-star inspections with $9,311 in total fines with 12 recent health deficiencies
6106 Health Center Lane, Fredericksburg, VA
(540) 785-1120
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
140
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Commonwealth Care Of Roanoke
Operator or chain grouping
Approved since
2008-05-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 4 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
0.47
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.41
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.23
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
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.64
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,660
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.22
Baseline 22.23% · Performance 19.78% · Measure score 4.22 · Achievement 3.57 · Improvement 4.22
Healthcare-associated infections
0
Baseline 10.14% · Performance 10.39% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.75
Baseline 45.76% · Performance 52.46% · Measure score 2.75 · Achievement 2.75 · Improvement 0
Adjusted total nurse staffing
0.87
Baseline 3.41 hours · Performance 3.33 hours · Measure score 0.87 · Achievement 0.87 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 15.63% |
10.72%
4.9 pts worse
|
Worse than the National Rate · Eligible stays 442 · Observed rate 17.87% · Lower 95% interval 12.71% |
| Discharge to community | 49.25% |
50.57%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 487 · Observed rate 43.53% · Lower 95% interval 45.06% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 335 · Denominator 335 |
| Falls with major injury | 0.3% |
0.77%
0.5 pts better
|
Numerator 1 · Denominator 335 |
| Discharge self-care score | 48.88% |
53.69%
4.8 pts worse
|
Numerator 109 · Denominator 223 |
| Discharge mobility score | 48.43% |
50.94%
2.5 pts worse
|
Numerator 108 · Denominator 223 |
| Pressure ulcers or injuries, new or worsened | 3.88% |
2.29%
1.6 pts worse
|
Numerator 13 · Denominator 335 · Adjusted rate 3.57% |
| Healthcare-associated infections requiring hospitalization | 10.39% |
7.12%
3.3 pts worse
|
Worse than the National Rate · Eligible stays 313 · Observed rate 11.18% · Lower 95% interval 7.7% |
| Staff COVID-19 vaccination coverage | 2.67% |
8.2%
5.5 pts worse
|
Numerator 4 · Denominator 150 |
| Staff flu vaccination coverage | 35.86% |
42%
6.1 pts worse
|
Numerator 71 · Denominator 198 |
| Discharge function score | 53.81% |
56.45%
2.6 pts worse
|
Numerator 120 · Denominator 223 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 261 · Denominator 261 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 29 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 39.88% |
25.2%
14.7 pts better
|
Numerator 67 · Denominator 168 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.4
0.2 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
91.2%
6.8 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.2% · Q4 96.3% · 4Q avg 98.0% |
| 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 | 5.9% |
3.6%
2.3 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 6.1% · Q3 5.7% · Q4 6.4% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
15.7%
15.7 pts better
|
11.4%
11.4 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 who lose too much weight | 8.0% |
5.7%
2.3 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 8.9% · Q3 8.9% · Q4 9.2% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.5% |
20.2%
6.7 pts better
|
19.6%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 14.9% · Q3 10.7% · Q4 10.9% · 4Q avg 13.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.3% |
15.0%
4.3 pts worse
|
16.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 19.8% · Q3 17.6% · Q4 14.8% · 4Q avg 19.3% · 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 | 33.6% |
17.5%
16.1 pts worse
|
16.3%
17.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.6% · Q2 38.9% · Q3 41.4% · Q4 18.4% · 4Q avg 33.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.8% |
15.7%
11.1 pts worse
|
14.9%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.3% · Q2 31.8% · Q3 23.7% · Q4 23.1% · 4Q avg 26.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.5%
0.2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
1.6%
0.4 pts worse
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.1% · Q3 1.9% · Q4 1.9% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.3% |
22.2%
2.1 pts worse
|
19.8%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 31.7% · Q3 20.2% · Q4 19.7% · 4Q avg 24.3% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
5.2%
0.7 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 6.7% · Q3 5.8% · Q4 3.8% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.7% |
74.6%
9.1 pts better
|
81.7%
2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.5% · Q2 84.4% · Q3 80.6% · Q4 78.3% · 4Q avg 83.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.7% |
11.7%
6 pts better
|
12.0%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.7% · Observed 5.6% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.2%
About the same
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 1.1% · Q3 2.0% · Q4 1.3% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.7% |
73.6%
13.1 pts better
|
79.7%
7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.5% |
22.0%
4.5 pts worse
|
23.9%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.5% · Observed 25.9% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-01-27 · Fire 2022-01-27
16 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2019-08-08 · Fire 2019-08-08
14 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-01-27
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-08-05
D · Potential for more than minimal harm
2022-01-27
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 2022-02-10
D · Potential for more than minimal harm
2022-01-27
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 2022-03-25
D · Potential for more than minimal harm
2022-01-27
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-03-25
D · Potential for more than minimal harm
2022-01-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-02-10
D · Potential for more than minimal harm
2022-01-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-03-02
D · Potential for more than minimal harm
2022-01-27
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-05-12
D · Potential for more than minimal harm
2022-01-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-12
E · Potential for more than minimal harm
2019-08-08
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-11-07
E · Potential for more than minimal harm
2019-08-08
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 2019-11-07
E · Potential for more than minimal harm
2019-08-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-11-18
E · Potential for more than minimal harm
2019-08-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-11-07
E · Potential for more than minimal harm
2019-08-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-07
E · Potential for more than minimal harm
2019-08-08
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-11-18
E · Potential for more than minimal harm
2019-08-08
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2019-11-07
D · Potential for more than minimal harm
2019-08-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-11-07
D · Potential for more than minimal harm
2019-08-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-11-07
D · Potential for more than minimal harm
2019-08-08
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2019-11-07
D · Potential for more than minimal harm
2019-08-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-11-07
D · Potential for more than minimal harm
2019-08-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-11-07
C · Minimal harm
2019-08-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-11-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-11-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-20
E · Potential for more than minimal harm
2024-12-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-12
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 2025-01-06
D · Potential for more than minimal harm
2024-12-12
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-01-06
G · Actual harm
2023-06-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-22
E · Potential for more than minimal harm
2023-06-07
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 2023-07-22
E · Potential for more than minimal harm
2023-06-07
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-07-22
D · Potential for more than minimal harm
2023-06-07
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 2023-07-22
D · Potential for more than minimal harm
2023-06-07
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-07-22
D · Potential for more than minimal harm
2023-06-07
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 2023-07-22
D · Potential for more than minimal harm
2023-06-07
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 2023-07-22
D · Potential for more than minimal harm
2023-06-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-22
D · Potential for more than minimal harm
2023-06-07
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 2023-07-22
D · Potential for more than minimal harm
2023-06-07
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 2023-07-22
F · Potential for more than minimal harm
2022-01-27
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2022-03-08
E · Potential for more than minimal harm
2022-01-27
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 2022-03-08
D · Potential for more than minimal harm
2022-01-27
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-03-08
D · Potential for more than minimal harm
2022-01-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-03-08
D · Potential for more than minimal harm
2022-01-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-03-08
D · Potential for more than minimal harm
2022-01-27
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 2022-03-08
D · Potential for more than minimal harm
2022-01-27
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 2022-03-08
D · Potential for more than minimal harm
2022-01-27
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 2022-03-08
D · Potential for more than minimal harm
2022-01-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-03-08
D · Potential for more than minimal harm
2022-01-27
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 2022-03-08
D · Potential for more than minimal harm
2022-01-27
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-03-08
D · Potential for more than minimal harm
2022-01-27
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 2022-03-08
D · Potential for more than minimal harm
2022-01-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-08
E · Potential for more than minimal harm
2019-08-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-09-10
E · Potential for more than minimal harm
2019-08-08
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 2019-09-10
E · Potential for more than minimal harm
2019-08-08
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 2019-09-10
D · Potential for more than minimal harm
2019-08-08
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 2019-09-10
D · Potential for more than minimal harm
2019-08-08
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 2019-09-10
D · Potential for more than minimal harm
2019-08-08
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 2019-09-10
D · Potential for more than minimal harm
2019-08-08
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 2019-09-10
D · Potential for more than minimal harm
2019-08-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-09-10
D · Potential for more than minimal harm
2019-08-08
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2019-09-10
D · Potential for more than minimal harm
2019-08-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-09-10
D · Potential for more than minimal harm
2019-08-08
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 2019-09-10
D · Potential for more than minimal harm
2019-08-08
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2019-09-10
D · Potential for more than minimal harm
2019-08-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-09-10
B · Minimal harm
2019-08-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-09-10
Penalties and ownership
What sits behind the stars
$9,311
2023-06-07
Fine
Fine · fine $9,311
Fine
Ownership
Dj Petrine LLC
5% Or Greater Direct Ownership Interest · Organization
Petrine, Deborah
5% Or Greater Indirect Ownership Interest · Individual
Petrine, James
5% Or Greater Indirect Ownership Interest · Individual
Bdsheffer LLC
5% Or Greater Direct Ownership Interest · Organization
Sheffer, Brady
5% Or Greater Indirect Ownership Interest · Individual
Goodall, Lury
5% Or Greater Direct Ownership Interest · Individual
Stallard, Patricia
5% Or Greater Direct Ownership Interest · Individual
Alesantrino, Joe
Corporate Officer · Individual
Commonwealth Care Of Roanoke Inc
Operational/Managerial Control · Organization
Petrine, Deborah
Corporate Officer · Individual
Sevier, John
W-2 Managing Employee · Individual
Tucker, David
Corporate Officer · Individual
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Fredericksburg Health And Rehab
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2-star overall rating with 2-star inspections with $9,311 in total fines with 17 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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1-star overall rating with 1-star inspections with 32 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
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4-star overall rating with 3-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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