Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
CARRIAGE HILL HEALTH & REHAB CENTER
FREDERICKSBURG, VA · 150 certified beds · Last Life Safety survey June 7, 2023
CMS Certification Number 495396 · first certified May 2008
Ownership
Operated by COMMONWEALTH CARE OF ROANOKE · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within VA
21 citations — more than 85% of the 289 certified nursing homes in VA. Compared within VA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 0 citations; the earlier surveys in the window averaged 10.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: January 2026 to January 2027. This facility’s last Life Safety survey was June 2023. Facilities in VA are typically surveyed 31–43 months after the last one (median 37), measured over 125 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 21 Life Safety citations above. The Physical Environment Index
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in VA, and nationally. Surveyors differ markedly between states, so the VA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 21 |
| Median facility in VA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 8, 2019 | 13 |
| January 27, 2022 | 8 |
| June 7, 2023 | 0 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2022-01-27 |
| K-0222 | 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. | 2 | 2022-01-27 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 2 | 2022-01-27 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2022-01-27 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2019-08-08 |
| K-0919 | Meet requirements for the use of electrical equipment. | 1 | 2019-08-08 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2019-08-08 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2019-08-08 |
What the citations cover
- Smoke Deficiencies 11
- Egress Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Construction Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 11 |
| Egress Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Construction Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 27, 2022 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0200 | Meet other general requirements. | Deficient, Provider has date of correction (August 5, 2022) |
| K-0222 | 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. | Deficient, Provider has date of correction (February 10, 2022) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (March 25, 2022) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (March 25, 2022) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (February 10, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 2, 2022) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Waiver has been granted (May 12, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Waiver has been granted (May 12, 2022) |
August 8, 2019 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (November 7, 2019) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (November 7, 2019) |
| K-0222 | 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. | Deficient, Provider has date of correction (November 7, 2019) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (November 18, 2019) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (November 7, 2019) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (November 7, 2019) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (November 7, 2019) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (November 7, 2019) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 7, 2019) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 7, 2019) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (November 18, 2019) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (November 7, 2019) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (November 7, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.