Cycle 1
Health 2021-12-02 · Fire 2021-12-02
14 health deficiencies
Top issue: Resident Rights (6 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Sterling, VA
Potomac Falls Health & Rehab Center
3-star overall rating with 3-star inspections with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
46531 Harry Byrd Highway, Sterling, VA
(703) 834-5800
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
147
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Commonwealth Care Of Roanoke
Operator or chain grouping
Approved since
1988-03-08
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
0.66
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.32
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
3.61
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
48%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,815
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9839
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.61% · Performance 21.60% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.38
Baseline 5.86% · Performance 7.12% · Measure score 2.38 · Achievement 2.38 · Improvement 0
Total nurse turnover
7.23
Baseline 42.24% · Performance 34.15% · Measure score 7.23 · Achievement 7.23 · Improvement 4.15
Adjusted total nurse staffing
0.63
Baseline 3.03 hours · Performance 3.26 hours · Measure score 0.63 · Achievement 0.63 · Improvement 0.33
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.97% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 402 · Observed rate 10.7% · Lower 95% interval 8.81% |
| Discharge to community | 60.32% |
50.57%
9.8 pts better
|
Better than the National Rate · Eligible stays 399 · Observed rate 53.63% · Lower 95% interval 55.24% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.66% |
95.27%
4.4 pts better
|
Numerator 297 · Denominator 298 |
| Falls with major injury | 1.34% |
0.77%
0.6 pts worse
|
Numerator 4 · Denominator 298 |
| Discharge self-care score | 36.76% |
53.69%
16.9 pts worse
|
Numerator 75 · Denominator 204 |
| Discharge mobility score | 27.94% |
50.94%
23 pts worse
|
Numerator 57 · Denominator 204 |
| Pressure ulcers or injuries, new or worsened | 1.35% |
2.29%
0.9 pts better
|
Numerator 4 · Denominator 297 · Adjusted rate 0.85% |
| Healthcare-associated infections requiring hospitalization | 7.12% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 282 · Observed rate 7.45% · Lower 95% interval 4.84% |
| Staff COVID-19 vaccination coverage | 8.02% |
8.2%
0.2 pts worse
|
Numerator 17 · Denominator 212 |
| Staff flu vaccination coverage | 38.18% |
42%
3.8 pts worse
|
Numerator 84 · Denominator 220 |
| Discharge function score | 29.9% |
56.45%
26.6 pts worse
|
Numerator 61 · Denominator 204 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 228 · Denominator 228 |
| Transfer of health information to patient | 97.44% |
96.28%
1.2 pts better
|
Numerator 38 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 35.22% |
25.2%
10 pts better
|
Numerator 56 · Denominator 159 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.2 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.4
0.7 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.7 · 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 | 98.2% |
94.0%
4.2 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.6%
0.6 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 5.1% · Q3 2.9% · Q4 1.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
15.7%
15 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
5.7%
0.1 pts better
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 4.7% · Q3 3.3% · Q4 6.7% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.0% |
20.2%
9.2 pts better
|
19.6%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 9.0% · Q3 10.8% · Q4 10.8% · 4Q avg 11.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.0% |
15.0%
3 pts better
|
16.7%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 12.5% · Q3 10.1% · Q4 13.5% · 4Q avg 12.0% · 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 | 24.2% |
17.5%
6.7 pts worse
|
16.3%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.3% · Q2 10.4% · Q3 31.9% · Q4 19.1% · 4Q avg 24.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.6% |
15.7%
0.1 pts better
|
14.9%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 13.6% · Q3 23.0% · Q4 8.4% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.5%
0.5 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.8% · Q3 0.7% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.6%
0.6 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.6% |
22.2%
1.4 pts worse
|
19.8%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 14.1% · Q3 25.8% · Q4 24.7% · 4Q avg 23.6% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
5.2%
0.2 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 4.9% · Q3 5.6% · Q4 5.7% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
74.6%
24 pts better
|
81.7%
16.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 99.2% · Q3 99.5% · Q4 98.6% · 4Q avg 98.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
11.7%
3.4 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 7.9% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.2%
0.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.7% · Q3 0.4% · Q4 1.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.2% |
73.6%
23.6 pts better
|
79.7%
17.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| 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 20.2% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2018-10-11 · Fire 2018-10-11
12 health deficiencies
Top issue: Resident Rights (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2017-03-23 · Fire 2017-03-23
11 health deficiencies
Top issue: Environmental (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2021-12-02
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-01-28
D · Potential for more than minimal harm
2021-12-02
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-01-28
F · Potential for more than minimal harm
2018-10-11
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2019-01-31
D · Potential for more than minimal harm
2018-10-11
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2019-01-31
D · Potential for more than minimal harm
2018-10-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-01-31
D · Potential for more than minimal harm
2018-10-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-01-31
D · Potential for more than minimal harm
2017-03-23
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 2017-05-10
D · Potential for more than minimal harm
2017-03-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2017-05-10
D · Potential for more than minimal harm
2017-03-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2017-05-10
D · Potential for more than minimal harm
2017-03-23
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2017-05-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2021-12-02
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 2022-01-11
E · Potential for more than minimal harm
2021-12-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-01-11
E · Potential for more than minimal harm
2021-12-02
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 2022-01-11
D · Potential for more than minimal harm
2021-12-02
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-02
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 2022-01-11
D · Potential for more than minimal harm
2021-12-02
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-02
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 2022-01-11
D · Potential for more than minimal harm
2021-12-02
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 2022-01-11
D · Potential for more than minimal harm
2021-12-02
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-02
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-02
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 2022-01-11
D · Potential for more than minimal harm
2021-12-02
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 2022-01-11
D · Potential for more than minimal harm
2021-12-02
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-01-11
D · Potential for more than minimal harm
2018-10-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2018-11-23
D · Potential for more than minimal harm
2018-10-11
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2018-11-23
D · Potential for more than minimal harm
2018-10-11
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2018-11-23
D · Potential for more than minimal harm
2018-10-11
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 2018-11-23
D · Potential for more than minimal harm
2018-10-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-11-23
D · Potential for more than minimal harm
2018-10-11
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 2018-11-23
D · Potential for more than minimal harm
2018-10-11
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2018-11-23
D · Potential for more than minimal harm
2018-10-11
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 2018-11-23
D · Potential for more than minimal harm
2018-10-11
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 2018-11-23
D · Potential for more than minimal harm
2018-10-11
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2018-11-23
D · Potential for more than minimal harm
2018-10-11
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2018-11-23
D · Potential for more than minimal harm
2018-10-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-11-23
K · Immediate jeopardy
2017-03-23
F323 · Environmental Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Corrected 2017-05-11
G · Actual harm
2017-03-23
F309 · Quality of Life and Care Deficiencies
Health
Provide necessary care and services to maintain or improve the highest well being of each resident .
Corrected 2017-05-11
F · Potential for more than minimal harm
2017-03-23
F371 · Nutrition and Dietary Deficiencies
Health
Store, cook, and serve food in a safe and clean way.
Corrected 2017-05-11
E · Potential for more than minimal harm
2017-03-23
F250 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2017-05-12
E · Potential for more than minimal harm
2017-03-23
F252 · Environmental Deficiencies
Health
Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible.
Corrected 2017-05-11
E · Potential for more than minimal harm
2017-03-23
F441 · Environmental Deficiencies
Health
Have a program that investigates, controls and keeps infection from spreading.
Corrected 2017-05-11
E · Potential for more than minimal harm
2017-03-23
F498 · Nursing and Physician Services Deficiencies
Health
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
Corrected 2017-05-11
D · Potential for more than minimal harm
2017-03-23
F157 · 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 2017-05-12
D · Potential for more than minimal harm
2017-03-23
F246 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2017-05-11
D · Potential for more than minimal harm
2017-03-23
F328 · Quality of Life and Care Deficiencies
Health
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
Corrected 2017-05-11
D · Potential for more than minimal harm
2017-03-23
F518 · Administration Deficiencies
Health
Train all employees on what to do in an emergency, and carry out unannounced staff drills.
Corrected 2017-05-11
Penalties and ownership
What sits behind the stars
Ownership
Nova Care LLC
5% Or Greater Direct Ownership Interest · Organization
Alesantrino, Joe
Corporate Officer · Individual
Bdsheffer LLC
5% Or Greater Indirect Ownership Interest · Organization
Commonwealth Care Of Roanoke Inc
Operational/Managerial Control · Organization
Dj Petrine LLC
5% Or Greater Indirect Ownership Interest · Organization
Goodall, Lury
5% Or Greater Indirect Ownership Interest · Individual
Petrine, Deborah
5% Or Greater Indirect Ownership Interest · Individual
Petrine, Deborah
Corporate Officer · Individual
Petrine, James
5% Or Greater Indirect Ownership Interest · Individual
Sheffer, Brady
5% Or Greater Indirect Ownership Interest · Individual
Stallard, Patricia
5% Or Greater Indirect Ownership Interest · Individual
Tucker, David
5% Or Greater Indirect Ownership Interest · Individual
Tucker, David
Corporate Officer · Individual
White, Brenda
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Johnson Cntr/Falcons Landing
Potomac Falls, VA
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Ashby Ponds Inc
Ashburn, VA
4-star overall rating with 3-star inspections with $9,438 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Dulles Health & Rehab Center
Herndon, VA
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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