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Nursing HomeMedicaid Investigative

Berea Health & Rehab Center

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

55 Brimley Drive, Fredericksburg, VA 2240690 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
4.2/5

based on 55 Google reviews

5
4
3
2
1
Berea Health & Rehab Center Nursing Home in Fredericksburg, VA — Street View
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6/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (2/5 stars)
  • Low staffing rating (2/5 stars)
  • Above-median deficiencies (19 vs median 11.0)
  • High staff turnover (68%)
  • High RN turnover (79%)

Below average in VA · Below recommended RN staffing · Above average staffing · Below chain average · $21,996 in fines

Source: Medicare data

What this means for your family

While Berea Health & Rehab offers a clean, modern environment and strong rehabilitation therapy, the facility struggles with consistent staffing, particularly on weekends. Families should be prepared to be highly involved in their loved one's daily care and oversight, as multiple reports indicate that response times to call lights and communication regarding medical changes can be unreliable.

Google Reviews

Google Reviews

55 reviews on Google
Berea Health & Rehab Center receives polarized feedback, with many families praising the modern, clean facility and effective physical therapy teams. However, a recurring pattern of critical concerns regarding staffing shortages, slow response times to call lights, and lapses in medical oversight suggests significant inconsistency in care quality. Families should weigh the positive reports of rehabilitation outcomes against serious allegations of neglect and communication failures.

Quality Themes

Tap a score for details
Food7.0Staff5.0Clean9.0Activities8.0Meds3.0Memory4.0Comms3.0ValueN/A

Strengths

  • Modern, clean, and well-maintained facility
  • Effective physical and occupational therapy programs
  • Professional and welcoming administrative staff
  • Compassionate individual nursing and CNA care

Concerns

  • Slow response times to call lights and requests for assistance (mentioned by 6 reviewers)
  • Inadequate staffing levels, particularly on weekends and evenings (mentioned by 4 reviewers)
  • Poor communication and lack of follow-up from management regarding complaints (mentioned by 4 reviewers)
  • Medical oversight lapses, including missed diagnoses and medication errors (mentioned by 3 reviewers)

Rating Trends

Tap a year to see what changed

2343.62022(7)4.22023(10)3.92024(11)4.32025(20)3.72026(3)

Distribution · 51 analyzed

5
38
4
0
3
1
2
2
1
10

How They Respond to Reviews

100%response rate

This facility actively engages with reviewer feedback.

Questions for Your Tour

  • 1I noticed your team is very active in responding to online feedback; how do you use that same level of communication to keep families updated on their loved one's daily progress?
  • 2With the facility's focus on physical and occupational therapy, how do you ensure that residents receive consistent support during evenings and weekends when staffing levels can be more challenging?
  • 3Could you walk me through your current process for call light response times to ensure that residents feel supported and heard throughout the day and night?
  • 4Given the importance of medication safety, what specific protocols or double-check systems do you have in place to prevent errors and ensure residents receive the correct care?
  • 5How do you approach the specific needs of memory care residents to ensure they feel engaged and safe within the community?
  • 6In the event of a medical concern or a change in health status, what is the standard procedure for notifying family members and coordinating with primary physicians?

Personalized based on this facility's data


Key Review Excerpts

My mom went there for rehab and almost died had I not forced them to send her to the hospital. I thought my mom was starting the dying process because she completely stopped eating while there.

Rehab family member · 2023☆☆☆☆

You ring the bell for assistance it takes 35 to 45 minutes for someone To respond, you could be on the floor and need assistance and they were still within that period of time.

Rehab patient · 2024☆☆☆☆

The building is well maintained and clean with spacious rooms and bathrooms for the residents. The IDT team of providers, nurses, CNAs, therapists, social workers and administrative staff work together to ensure the residents get quality care.

Family member · 2025★★★★★
Source: 55 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.63hrs
83%
Registered nurses for medical care
Total Nursing
3.96hrs
97%
All nurses + aides combined
Staff Turnover
64%
Lower is better (< 30% = good)
RN Turnover
64%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
4/ 5
Better Than Avg

9

measures

Worse Than Avg

8

measures

Long-Stay Residents
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility8.0%
Better than Avg
Here
8.0%
US
19.5%
VA
20.4%
😔

Residents with depression symptoms

↓ Lower is better
This Facility22.9%
Worse than Avg
Here
22.9%
US
12.1%
VA
16.9%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on antipsychotic medication

↓ Lower is better
This Facility5.4%
Better than Avg
Here
5.4%
US
15.5%
VA
14.2%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility85.8%
Worse than Avg
Here
85.8%
US
93.4%
VA
91.0%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility25.7%
Worse than Avg
Here
25.7%
US
19.4%
VA
22.0%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility11.5%
Better than Avg
Here
11.5%
US
15.3%
VA
16.4%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility50.6%
Worse than Avg
Here
50.6%
US
81.8%
VA
73.9%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility62.5%
Worse than Avg
Here
62.5%
US
79.8%
VA
73.6%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility1.3%
Better than Avg
Here
1.3%
US
1.6%
VA
1.2%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

12deficiencies
Near state avg (14.5)
6 complaint-triggered
$21,996 in fines

Families have filed complaints triggering inspections, with recurring issues in treatment and care quality, family communication, and care planning. The facility has struggled with properly notifying families about resident changes and providing appropriate care according to resident needs and doctor orders, with some problems persisting across multiple surveys from 2022 to 2024. While all deficiencies show correction dates, the pattern of repeated issues in core care areas warrants careful consideration during any visit.

Mar 5, 2026Routine
12
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0887Potential for harm · IsolatedCorrected

Infection Control Deficiencies

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.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

0806Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

0883Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

0211Potential for harm · IsolatedCorrected

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

0222Potential for harm · IsolatedCorrected

Egress Deficiencies

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.

Dec 4, 2025Complaint
2
0580Potential for harm · PatternCorrected

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

0684Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Jul 17, 2024Complaint
1
0700Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

Jun 2, 2023Routine
18
0689Actual harm · IsolatedResolved (past non-compliance)

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0324Potential for harm · WidespreadCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0345Potential for harm · WidespreadCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0372Potential for harm · WidespreadCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0656Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0698Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

0842Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0553Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

0622Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0625Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0676Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0883Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

0732Minimal · WidespreadCorrected

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Jun 2, 2023Complaint
3
0580Actual harm · IsolatedCorrected

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

0658Actual harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0713Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

Provide or arrange emergency care by a doctor 24 hours a day.

Jan 12, 2022Routine
3
0727Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

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.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Ownership & Operations

Who Operates This Facility

Owner / Operator

Berea Health & Rehab Center

Organization Type

for profit

Chain Affiliation

Chain Name

Saber Healthcare Group

Chain Size

127 facilities nationwide

Chain avg rating: 3.0/5 · Rank 93 of 125

Ownership & Management

Owners

Saber Healthcare Holdings LLC

Owner · Organization

Benjamin N. Volpe Family Dynasty Trust (dated December 29, 2020)

Owner (parent company) · Organization

Bnv Dynasty LLC

Owner (parent company) · Organization

Decanted William I. Weisberg Family Dynasty Trust (dated Sept 30, 2020

Owner (parent company) · Organization

Wiw Dynasty LLC

Owner (parent company) · Organization

Weisberg, William

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Key personnel

Weisberg, WilliamOfficer / DirectorNicoluzakis, GregoryOfficer / DirectorVolpe, BenjaminOfficer / DirectorWeisberg, WilliamOfficer / DirectorShg Management LLCManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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