The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited June 2023 — isolated incident, actual harm.
View the original federal record
F-Tag 686 — 42 CFR §483.25(b) — S/S: G
Nursing home report
CARRIAGE HILL HEALTH & REHAB CENTER
FREDERICKSBURG, VA · Medicare-certified · 150 beds
In good standing
For-profitChain member
3 of 5 overall
3 out of 5 stars overall. Health inspection, staffing, and quality measures are also 3 stars; reported nurse staffing is 3.84 hours per resident per day versus the 4.1-hour federal benchmark, with $0 in fines over the last 24 months and recent inspection citations related to pressure ulcer care, visitor rights, and following care orders.
Facility ratings
Health inspections
Staffing
3.843 hrs/resident/day
Quality measures
Last inspection: November 19, 2025Penalties, last 24 months: $0
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.843.
Staffing detail
- Registered nurses
- 0.51
- Licensed practical nurses
- 1.08
- Nurse aides
- 2.25
- Weekend nursing
- 3.40
Hours per resident per day.
Total staff turnover: 46%
Registered nurse turnover: 44%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
15.3%Improving
Residents with a fall causing major injury
6%Steady
Residents with pressure ulcers (bedsores)
5.7%Steady
Residents with a urinary tract infection
1.5%Steady
Residents who lost too much weight
8.8%Improving
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
25.8%Improving
Residents whose ability to walk got worse
28.4%Improving
Show all measures
Long-stay residents on antianxiety or sleep medication
11.6%Improving
Short-stay residents newly given an antipsychotic
1.4%Steady
Residents with a long-term catheter
0%Steady
Residents with new or worsening incontinence
25.6%Steady
Residents with depressive symptoms
0%Steady
Long-stay residents given the seasonal flu vaccine
99.1%Steady
Long-stay residents given the pneumonia vaccine
97.8%Worsening
Short-stay residents given the seasonal flu vaccine
86.7%Steady
Short-stay residents given the pneumonia vaccine
82.4%Improving
What the inspectors found
The nursing home failed to honor a resident’s right to receive visitors of their choosing at the time they wanted. Cited January 2022 — widespread issue, potential for harm.
View the original federal record
F-Tag 563 — 42 CFR §483.10 — S/S: F
The nursing home failed to provide appropriate treatment and care according to residents' orders, preferences, and goals. Cited December 2024 — limited pattern, potential for harm.
View the original federal record
F-Tag 684 — 42 CFR §483.25 — S/S: E
The nursing home failed to develop and carry out a complete care plan that met each resident’s needs with clear steps and timelines. Cited June 2023 — limited pattern, potential for harm.
View the original federal record
F-Tag 656 — 42 CFR §483.21(b)(1) — S/S: E
The home failed to provide safe, appropriate dialysis care for a resident who needed it. Cited June 2023 — limited pattern, potential for harm.
View the original federal record
F-Tag 698 — 42 CFR §483.25(l) — S/S: E
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 3 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 10 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 1 fine · $9,311 in total fines.
- $9,311
Federal fine
Jun 7, 2023
Operator & ownership
- Ownership
- For profit - Limited Liability company
- Chain
- Part of COMMONWEALTH CARE OF ROANOKE · 12 homes · 3.8 stars avg
- Occupancy
- 138.5 residents on an average day (92% of 150 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 18 years
The most recent standard health inspection was more than two years ago.
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.