Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carriage Hill Health & Rehab Center during CMS and state inspections, most recent first.
A resident's physician order for sacral wound care was not transcribed to the MAR or TAR due to a nurse failing to select a schedule in the electronic system. Staff interviews confirmed that without a schedule, the order remained in the system and was not carried over to the administration records, contrary to facility policy.
A resident with an open sacral wound was not thoroughly assessed or treated upon admission due to a failure to document the physician's order in the treatment administration record. For several days, the wound was not monitored or treated as required, and daily assessments failed to identify the presence of a pressure injury. The deficiency was confirmed through record review and staff interviews.
Facility staff failed to provide timely care and medication administration for several residents. A resident did not receive a timely physical assessment after a change in status, leading to a delayed COVID-19 diagnosis. Additionally, multiple residents received medications late, beyond the acceptable window, indicating a failure to follow physician's orders. The facility lacked policies on notifying providers for assessments and on medication timing, contributing to these deficiencies.
Facility staff failed to notify a provider to assess a resident with a change in status for over 29 hours. The resident appeared lethargic and expressed feeling unwell, but no further assessment was conducted until the resident tested positive for COVID-19. A nurse practitioner was unaware of the need for assessment until after the diagnosis, and the facility's policy on notifying changes was not followed.
A resident's pacemaker monitor was not maintained in working order at their bedside. The monitor was found in an LPN's office after being missing for an undetermined period. Despite the facility's policy to maintain equipment in safe condition, staff could not explain why the cardiology office did not alert them about the monitor's absence. Administrative staff were informed of the issue.
Failure to Transcribe Physician's Wound Care Order to Administration Records
Penalty
Summary
Facility staff failed to follow professional standards of practice for one resident by not properly transcribing a physician's order for wound care treatment. Specifically, a physician's order dated 5/2/25 directed that the resident's sacral wound be cleansed with normal saline, patted dry, and covered with a foam dressing. Upon review of the resident's clinical record, it was found that this order was not present on the medication administration record (MAR) or the treatment administration record (TAR) for May 2025. Interviews with staff revealed that the nurse who entered the order into the computer system did not select a schedule for the treatment, resulting in the order not being carried over to the MAR or TAR. The facility's policy requires that all medication and treatment orders be completely transcribed onto the appropriate administration records. The deficiency was confirmed through staff interviews and review of facility documentation.
Failure to Assess and Treat Pressure Injury on Admission
Penalty
Summary
Facility staff failed to provide appropriate care and services for a pressure injury for one resident. Upon admission, the resident was documented as having an open wound on the sacrum, but the assessment lacked further descriptors such as measurements, stage, or wound characteristics. Although a physician's order was entered to cleanse the wound and apply a foam dressing, this order was not reflected in the medication or treatment administration records due to a scheduling error in the computer system. As a result, there was no evidence that the prescribed treatment was provided for three consecutive days. During this period, daily skilled assessments incorrectly indicated that the resident did not have impaired skin or a wound being monitored or treated. A subsequent body audit identified a stage three pressure injury on the sacrum, with specific measurements documented. Staff interviews confirmed that wound assessments and treatments are typically communicated and documented via the treatment administration record, but this process failed in this instance, leading to a lack of timely and appropriate wound care.
Failure to Provide Timely Care and Medication Administration
Penalty
Summary
The facility staff failed to provide adequate care and services to promote the highest level of well-being for several residents. For Resident #10, the staff did not conduct a timely physical assessment after a noted change in the resident's status, despite the resident expressing that she did not feel well. This lack of assessment persisted for over 29 hours until the resident tested positive for COVID-19. The facility lacked a policy for notifying a provider when a physical assessment was needed, contributing to the delay in care. For Residents #4, #5, #6, and #2, the facility staff failed to administer medications in a timely manner, as per physician's orders. The medication administration records revealed multiple instances where medications were given late, beyond the acceptable window of 60 minutes before or after the scheduled time. Interviews with LPNs confirmed that administering medications outside this window constitutes a failure to follow physician's orders. The facility's policy on medication administration did not include guidance on the timing of medication administration, which may have contributed to the repeated delays. The facility's administrative and clinical leadership were informed of these concerns, but no additional information or corrective actions were provided prior to the survey exit.
Failure to Notify Provider of Resident's Change in Status
Penalty
Summary
The facility staff failed to notify a provider to assess a resident, identified as having a change in status, for more than 29 hours. On 7/31/24, the resident was noted to be quieter and appeared lethargic, although their vitals were within normal limits. The resident expressed feeling unwell, but no further physical assessment was conducted by another nurse or provider until the resident tested positive for COVID-19 on 8/1/24. The nurse who documented the resident's condition was unavailable during the survey, and there was no record of a provider being notified for an assessment. Interviews with facility staff revealed that a nurse practitioner was unaware of any request to assess the resident until after the COVID-19 diagnosis. The nurse practitioner stated that she or another provider is present in the facility five days a week and checks a list of residents needing assessment regularly. An LPN stated that she would document any request for a provider assessment in a progress note, including the provider's response. The facility's policy requires prompt notification of changes in a resident's condition to the patient, physician, and legal representative, but this was not adhered to in this case.
Failure to Maintain Resident's Pacemaker Monitor in Working Order
Penalty
Summary
The facility staff failed to maintain the pacemaker monitor of Resident #2 in working order at the resident's bedside. Observations on multiple occasions confirmed that the pacemaker monitor was functioning properly when it was at the resident's bedside, as indicated by the green light. However, during an interview, LPN #3 revealed that upon returning from vacation, she found the monitor in her office, and it was unclear how long it had been there. The resident's daughter had raised concerns about the monitor's absence, and LPN #3 could not determine how long it had been missing from the resident's bedside. LPN #1, who regularly cared for Resident #2, noted that the monitor was missing from the room after returning from her vacation. She and LPN #3 found the monitor in LPN #3's office and returned it to the resident's bedside, where it resumed functioning correctly. The facility's policy requires maintaining all patient care equipment in safe operating condition, but the staff could not explain why the cardiology office did not alert them about the monitor's malfunction. The administrative staff, including the administrator and director of nursing, were informed of these concerns.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fredericksburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fredericksburg Health And Rehab | 1.2 mi | — | 2 | 0 |
| Woodmont Center | 5.4 mi | — | 5 | 0 |
| Falls Run Nursing And Rehabilitation | 5.9 mi | — | 0 | 0 |
| Berea Health & Rehab Center | 5.9 mi | — | 14 | 0 |
| Heritage Hall King George | 19.1 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.