Cycle 1
Health 2023-03-16 · Fire 2023-03-16
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fredericksburg, VA
Falls Run Nursing And Rehabilitation
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
140 Brimley Drive, Fredericksburg, VA
(540) 752-0111
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
90
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Saber Healthcare Group
Operator or chain grouping
Approved since
2010-10-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
126 facilities
Chain averages 3 overall / 3 health / 3 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
0.72
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.96
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
3.41
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.60
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
3.77
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,507
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.10
Composite VBP score used to determine payment impact.
Payment multiplier
1.0112
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 19.60% · Performance 16.91% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
3.89
Baseline 6.91% · Performance 6.67% · Measure score 3.89 · Achievement 3.89 · Improvement 0.75
Total nurse turnover
6.61
Baseline 47.56% · Performance 36.67% · Measure score 6.61 · Achievement 6.61 · Improvement 4.30
Adjusted total nurse staffing
1.94
Baseline 3.43 hours · Performance 3.63 hours · Measure score 1.94 · Achievement 1.94 · Improvement 0.33
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.58% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 419 · Observed rate 12.17% · Lower 95% interval 9.74% |
| Discharge to community | 59.4% |
50.57%
8.8 pts better
|
Better than the National Rate · Eligible stays 425 · Observed rate 54.35% · Lower 95% interval 54.08% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.96% |
95.27%
2.7 pts better
|
Numerator 240 · Denominator 245 |
| Falls with major injury | 0.82% |
0.77%
About the same
|
Numerator 2 · Denominator 245 |
| Discharge self-care score | 70.2% |
53.69%
16.5 pts better
|
Numerator 139 · Denominator 198 |
| Discharge mobility score | 59.6% |
50.94%
8.7 pts better
|
Numerator 118 · Denominator 198 |
| Pressure ulcers or injuries, new or worsened | 0.41% |
2.29%
1.9 pts better
|
Numerator 1 · Denominator 245 · Adjusted rate 0.36% |
| Healthcare-associated infections requiring hospitalization | 6.67% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 253 · Observed rate 5.93% · Lower 95% interval 4.27% |
| Staff COVID-19 vaccination coverage | 6.85% |
8.2%
1.3 pts worse
|
Numerator 10 · Denominator 146 |
| Staff flu vaccination coverage | 40.08% |
42%
1.9 pts worse
|
Numerator 105 · Denominator 262 |
| Discharge function score | 65.15% |
56.45%
8.7 pts better
|
Numerator 129 · Denominator 198 |
| Transfer of health information to provider | 92% |
95.95%
4 pts worse
|
Numerator 46 · Denominator 50 |
| Transfer of health information to patient | 93.22% |
96.28%
3.1 pts worse
|
Numerator 165 · Denominator 177 |
| Resident COVID-19 vaccinations up to date | 17.65% |
25.2%
7.6 pts worse
|
Numerator 21 · Denominator 119 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.9 · Expected 2.3 · 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 1.2 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 0.4% |
3.6%
3.2 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.2% |
15.7%
5.5 pts better
|
11.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.8% · Q3 12.5% · Q4 22.4% · 4Q avg 10.2% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.7%
5.7 pts better
|
5.4%
5.4 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 received an antianxiety or hypnotic medication | 21.3% |
20.2%
1.1 pts worse
|
19.6%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 27.3% · Q3 17.1% · Q4 19.4% · 4Q avg 21.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
15.0%
3.9 pts better
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 15.0% · Q3 11.4% · Q4 5.7% · 4Q avg 11.1% · 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 | 17.3% |
17.5%
0.2 pts better
|
16.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 8.0% · Q3 24.3% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.0% |
15.7%
7.7 pts better
|
14.9%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.3% · Q3 13.2% · Q4 17.1% · 4Q avg 8.0% · 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 | 0.4% |
1.6%
1.2 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.0% |
22.2%
2.8 pts worse
|
19.8%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 18.4% · Q3 34.0% · Q4 27.6% · 4Q avg 25.0% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
5.2%
3 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.1% · Q3 2.3% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
74.6%
25.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.0% |
11.7%
6.7 pts better
|
12.0%
7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.0% · Observed 4.6% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.2%
0.9 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.6% · Q4 0.6% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.5% |
73.6%
25.9 pts better
|
79.7%
19.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.5% |
22.0%
0.5 pts better
|
23.9%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 19.2% · Expected 21.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-08-26 · Fire 2021-08-26
9 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-09-06 · Fire 2019-09-06
10 health deficiencies
Top issue: Resident Rights (4 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-03-16
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-05-09
F · Potential for more than minimal harm
2019-09-06
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 2019-10-01
F · Potential for more than minimal harm
2019-09-06
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2019-10-01
D · Potential for more than minimal harm
2019-09-06
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 2019-10-01
D · Potential for more than minimal harm
2019-09-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-10-01
D · Potential for more than minimal harm
2019-09-06
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2019-10-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2023-03-16
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 2023-04-14
E · Potential for more than minimal harm
2023-03-16
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-04-14
E · Potential for more than minimal harm
2023-03-16
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-16
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-16
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 2022-03-21
D · Potential for more than minimal harm
2023-03-16
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 2023-04-14
D · Potential for more than minimal harm
2023-03-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-16
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 2023-04-14
D · Potential for more than minimal harm
2023-03-16
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 2023-04-14
E · Potential for more than minimal harm
2021-08-26
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 2021-09-22
E · Potential for more than minimal harm
2021-08-26
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 2021-09-22
D · Potential for more than minimal harm
2021-08-26
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-09-22
D · Potential for more than minimal harm
2021-08-26
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 2021-09-22
D · Potential for more than minimal harm
2021-08-26
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 2021-09-22
D · Potential for more than minimal harm
2021-08-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-09-22
D · Potential for more than minimal harm
2021-08-26
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2021-09-22
D · Potential for more than minimal harm
2021-08-26
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-09-22
D · Potential for more than minimal harm
2021-08-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-09-29
E · Potential for more than minimal harm
2019-09-06
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 2019-10-01
E · Potential for more than minimal harm
2019-09-06
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 2019-10-01
D · Potential for more than minimal harm
2019-09-06
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2019-10-01
D · Potential for more than minimal harm
2019-09-06
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 2019-10-01
D · Potential for more than minimal harm
2019-09-06
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 2019-10-01
D · Potential for more than minimal harm
2019-09-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-10-01
D · Potential for more than minimal harm
2019-09-06
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 2019-10-01
D · Potential for more than minimal harm
2019-09-06
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 2019-10-01
D · Potential for more than minimal harm
2019-09-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-10-01
D · Potential for more than minimal harm
2019-09-06
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2019-10-01
Penalties and ownership
What sits behind the stars
Ownership
Saber Healthcare Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Benjamin N. Volpe Family Dynasty Trust (Dated December 29, 2020)
5% Or Greater Indirect Ownership Interest · Organization
Bnv Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Decanted William I. Weisberg Family Dynasty Trust (Dated Sept 30, 2020
5% Or Greater Indirect Ownership Interest · Organization
Kulp, Jeffrey
Operational/Managerial Control · Individual
Nicoluzakis, Gregory
Corporate Officer · Individual
Shg Management LLC
Operational/Managerial Control · Organization
Volpe, Benjamin
Corporate Director · Individual
Volpe, Benjamin
Corporate Officer · Individual
Weisberg, William
Corporate Director · Individual
Weisberg, William
Corporate Officer · Individual
Wiw Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
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Berea Health & Rehab Center
Fredericksburg, VA
2-star overall rating with 2-star inspections with $21,996 in total fines with 19 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Fredericksburg Health And Rehab
Fredericksburg, VA
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
#3
Woodmont Center
Fredericksburg, VA
1-star overall rating with 1-star inspections with 32 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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