Home / Virginia / Fredericksburg
Berea Health & Rehab Center
55 Brimley Drive, Fredericksburg, VA 22406 · Stafford County · (540) 701-9480
90 certified beds, about 83 residents a day · For profit - Corporation · Medicare and Medicaid since 2022
CMS Care Compare ratings, data as of September 1, 2026 · CCN 495431 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on March 5, 2026, inspectors cited 10 health deficiencies (the Virginia average is 14.3, the national average 9.2).
Of 33 health citations since January 2022, 3 were rated as actual harm or immediate jeopardy to residents.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 4.01 hours per resident per day, against 3.76 across Virginia and 3.86 nationally. Registered nurses accounted for 0.71 of those hours.
65.4% of nursing staff left within the year CMS measured (Virginia average 48.1%).
CMS links it to Saber Healthcare Group, an affiliated group of 126 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 33 health citations on file.
March 5, 2026Standard inspection · 10 citations
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, staff interview, and facility document review, it was determined that the facility staff failed to store food, in one of one kitchens, in a sanitary manner.
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to follow infection control practices for two of 36 residents in the survey sample, Residents #26 and #17 and in one of one laundry room.
- D Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to promote dignity for one of 36 residents in the survey sample, Resident #75.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observations, staff interview facility document review and clinical record review, it was determined the facility staff failed to develop/implement the care plan for three of 36 residents in the survey sample, Resident #6, Resident #4 and Resident #43.
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to follow professional standards of practice to promote residents highest level of well-being for one of eight residents in the medication observation sample, Resident #34.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to implement fall precautions for one of 36 residents in the survey sample, Resident #4. For Resident #4 (R4), the facility staff failed to implement fall mats on both sides of the bed when the resident was in bed. On 3/3/26 at 2:02 p.m., and 3/4/26 at 8:38 a.m., R4 was observed lying in bed. A floor mat was observed on the left side of the bed. No floor mat was observed on the right side of the bed. The mat was observed rolled up, against the wall, in the corner of the room. R4's comprehensive care plan dated 11/19/25 documented, Resident has had an actual fall and is at risk for fall r/t (related to) muscle weakness/other reduced mobility/osteoarthritis, psychotropic med use, incontinence, impaired safety awareness/dementia. Bilateral floor mats. [...]
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to maintain a catheter bag in a sanitary manner for one of 36 residents in the survey sample, Residents #43.
- D Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to honor a food allergy for one of 36 residents in the survey sample, Resident #15.
- D Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to administer a vaccine for one of five residents in the immunization record review, Residents # 27.
- D Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to administer a vaccine for one of five residents in the immunization record review, Residents # 27.
December 4, 2025Complaint inspection · 2 citations
- E Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to preserve a resident's right for the notification of the provider and RR (resident representative) of a change in condition for two of five residents in the survey sample, Residents #1 and #2.
- E Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to follow the provider's order for the administration of insulin for two of five residents in the survey sample, Residents #1 and #2.
July 17, 2024Complaint inspection · 1 citation
- D 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.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence documentation of current side rail assessment and consent for one of six residents in the survey sample, Resident #2.
June 2, 2023Standard inspection · 17 citations
- G Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to immediately notify the physician of a significant change in condition for one of 34 residents, Resident #65, which constituted harm.
- G Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to follow professional standards of quality for two of 34 residents in the survey sample, Resident #18 and Resident #65, which resulted in harm for Resident #65.
- G Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide the proper assistance while providing ADL (activities of daily living) care which resulted in a fall from the bed for one of 34 residents in the survey sample, Resident #219. The resident sustained a right leg fracture which constituted harm cited at past non-compliance.
- E Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for five of 34 residents, Residents #56, #59, #18, #65, and #22.
- E Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to maintain ongoing communication with the dialysis center for two of 34 residents in the survey sample, Residents #22 and #35.
- E Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to ensure complete and accurate documentation for two of 34 residents, Resident #58 and Resident #268.
- D Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on resident interview, staff interview, clinical record review and facility record review, it was determined that the facility staff failed to ensure one of 34 residents were provided the opportunity to participate in the care planning process, Resident #18.
- D 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.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide the required documentation upon transfer to the hospital for two of 34 residents in the survey sample, Residents #15 and #58.
- D 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.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide a bed hold notice upon transfer to the hospital for one of 34 residents in the survey sample, Resident #15.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interview and clinical record review, it was determined the facility staff failed to accurately complete two MDS (minimum data set) assessments for one of 34 residents in the survey sample, Resident #24.
- D Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to promote a residents ability to communicate independently for one of 34 residents, Resident #56.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one of 34 residents in the survey sample, received the care and services in accordance with professional standards and the comprehensive care plan for Resident #22.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide respiratory care and services consistent with professional standards of practice for two of 34 residents, Resident #59 and Resident #122.
- D Provide or arrange emergency care by a doctor 24 hours a day.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to ensure on-call physician availability 24 hours per day for one of 34 residents, Resident #65.
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on resident interview, clinical record review, staff interview and facility document review it was determined that the facility staff failed to ensure that medications were available for administration for one of 34 residents in the survey sample, Residents #18.
- D Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed ensure two of five residents, reviewed for immunization status, had evidence of pneumococcal immunizations in the clinical record, Residents #35 and #58.
- C Post nurse staffing information every day.
Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to post current daily nurse staffing information for two of three survey dates.
January 12, 2022Standard inspection · 3 citations
- F Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to maintain RN (registered nurse) coverage for eight hours a day for every day.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one of two residents in the survey sample, (Resident #1), received the care and services in accordance with professional standards and the comprehensive care plan. The facility staff failed to administer medications for high blood pressure per the physician order for Resident #1.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview, family interview, facility document review and clinical record review, it was determined the facility staff failed to maintain a complete and accurate clinical record for one of two residents in the survey sample, Resident #1. The facility staff failed to document the education provided to the responsible party regarding the influenza immunization.
Fire safety inspections
6 fire safety citations on file: 2 on March 5, 2026, 4 on June 2, 2023.
Every fire safety citation6 citations
- D Keep aisles, corridors, and exits free of obstruction in case of emergency.
- D 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.
- F Provide properly protected cooking facilities.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Virginia | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.01 | 3.76 | 3.86 |
| Registered nurses | 0.71 | 0.69 | 0.69 |
| All nursing staff on weekends | 3.56 | 3.29 | 3.42 |
| Nurse aides | 2.18 | ||
| Licensed practical nurses | 1.11 | ||
| Nursing staff turnover (share who left in a year) | 65.4% | 48.1% | 45.8% |
| Registered nurse turnover | 64.3% | 48.2% | 42.9% |
| Administrators who left | 1 |
CMS expects 4.52 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.19 on weekdays and 3.56 on weekends, 15% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.3% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.81 in April to June 2025 to 4.01 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.01 | 0.71 | 4.19 | 3.56 | 0.3% | 0 of 90 | 83 |
| Oct to Dec 2025 | 3.96 | 0.63 | 4.12 | 3.55 | 1.1% | 0 of 92 | 83 |
| Jul to Sep 2025 | 3.82 | 0.46 | 4.02 | 3.32 | 1.1% | 0 of 92 | 82 |
| Apr to Jun 2025 | 3.81 | 0.61 | 3.96 | 3.42 | 1.0% | 0 of 91 | 82 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Virginia, Jan to Mar 2026 | 3.58 | 0.56 | 3.76 | 3.12 | 5.7% | 0.2% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Virginia | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 19.7 | 14.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.2 | 1.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 3.6 | 3.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.4 | 1.3 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 11.1 | 15.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 3.0 | 4.7 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 1.1 | 14.2 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 29.6 | 22.3 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 17.8 | 11.5 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.8 | 1.5 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.5 | 1.5 | 1.8 |
Owners and operators
Legal business name: STAFFORD II HEALTHCARE GROUP, LLC. CMS links this home to Saber Healthcare Group, a group of 126 nursing homes averaging 2.9 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Saber Healthcare Holdings LLC | Direct ownership interest | Organization | 11/15/2021 | |
| Benjamin N. Volpe Family Dynasty Trust (dated December 29, 2020) | Indirect ownership interest | Organization | 01/01/2023 | |
| Bnv Dynasty LLC | Indirect ownership interest | Organization | 01/01/2023 | |
| Decanted William I. Weisberg Family Dynasty Trust (dated Sept 30, 2020 | Indirect ownership interest | Organization | 01/01/2023 | |
| Wiw Dynasty LLC | Indirect ownership interest | Organization | 01/01/2023 | |
| Weisberg, William | Corporate director | Individual | 11/15/2021 | |
| Nicoluzakis, Gregory | Corporate officer | Individual | 11/15/2021 | |
| Volpe, Benjamin | Corporate officer | Individual | 11/15/2021 | |
| Weisberg, William | Corporate officer | Individual | 11/15/2021 | |
| Shg Management LLC | Operational/managerial control | Organization | 11/15/2021 | |
| Hopkins, Joseph | Operational/managerial control | Individual | 05/08/2023 | |
| Weisberg, William | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 02/09/2026 | |
| Benjamin N. Volpe Family Dynasty Trust (dated December 29, 2020) | Adp of the SNF | Organization | 11/01/2023 | |
| Berea Re Group, LLC | Adp of the SNF | Organization | 11/01/2023 | |
| Bnv Dynasty LLC | Adp of the SNF | Organization | 11/01/2023 | |
| Citrin Cooperman Advisors LLC | Adp of the SNF | Organization | 11/15/2021 | |
| Decanted William I. Weisberg Family Dynasty Trust (dated Sept 30, 2020 | Adp of the SNF | Organization | 11/01/2023 | |
| Saber Governance LLC | Adp of the SNF | Organization | 11/15/2021 | |
| Saber Healthcare Group LLC | Adp of the SNF | Organization | 11/15/2021 | |
| Shg Management LLC | Adp of the SNF | Organization | 11/15/2021 | |
| Walker & Associates PC | Adp of the SNF | Organization | 11/15/2021 | |
| Wiw Dynasty LLC | Adp of the SNF | Organization | 11/01/2023 | |
| Bebars, Hosameldin | Adp of the SNF | Individual | 01/31/2025 | |
| Hopkins, Joseph | Adp of the SNF | Individual | 05/08/2023 | |
| Nicoluzakis, Gregory | Adp of the SNF | Individual | 11/15/2021 | |
| Volpe, Benjamin | Adp of the SNF | Individual | 11/15/2021 | |
| Weisberg, William | Adp of the SNF | Individual | 11/15/2021 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 10 problems in this area, most recently on March 5, 2026: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
- When is the care plan meeting, and can family attend it?Inspectors cited 7 problems in this area, most recently on March 5, 2026: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 6 problems in this area, most recently on March 5, 2026: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights."
- What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 4 problems in this area, most recently on March 5, 2026: "Provide and implement an infection prevention and control program."
- How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.
Other nursing homes nearby
- Falls Run Nursing and Rehabilitation Fredericksburg, 0 mi · 4 of 5 stars · 28 citations
- Fredericksburg Health and Rehab Fredericksburg, 5.4 mi · 2 of 5 stars · 46 citations
- Woodmont Center Fredericksburg, 5.6 mi · 1 of 5 stars · 74 citations
- Carriage Hill Health & Rehab Center Fredericksburg, 5.9 mi · 3 of 5 stars · 42 citations
- Heritage Hall King George King George, 18.2 mi · 2 of 5 stars · 53 citations
- Belmont Bay Rehabilitation and Healthcare Center Woodbridge, 23.3 mi · 3 of 5 stars · 54 citations
- Bowling Green Health & Rehabilitation Center Bowling Green, 23.7 mi · 3 of 5 stars · 53 citations
Virginia contacts for a concern about a nursing home
These are the official offices in Virginia. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Virginia Department of Health, Office of Licensure and Certification, Division of Long-Term Care Services, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Virginia Office of the State Long-Term Care Ombudsman, 800-552-5019. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: VDH Nursing Home and ICF/IID Inspections and Surveys, where Virginia publishes its own records on licensed homes.
Common questions
- What is Berea Health & Rehab Center's Medicare star rating?
- CMS rates Berea Health & Rehab Center 2 out of 5 stars overall, with 2 for health inspections, 2 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Berea Health & Rehab Center get at its last inspection?
- 10 health deficiencies at the standard inspection on March 5, 2026. The Virginia average is 14.3.
- Has Berea Health & Rehab Center been fined?
- CMS lists no fines in the last three years.
- Does Berea Health & Rehab Center accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Berea Health & Rehab Center?
- CMS lists 27 owners and managers, and links the home to Saber Healthcare Group. Legal business name: STAFFORD II HEALTHCARE GROUP, LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.