Potomac Falls Health & Rehab Center
46531 Harry Byrd Highway, Sterling, VA 20164 · Loudoun County · 150 certified beds · avg 147 residents/day · certified since Mar 8, 1988
Part of chain: COMMONWEALTH CARE OF ROANOKE (12 facilities, chain avg rating 3.6★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Mar 23, 2017 · F-0323
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent avoidable accidents like falls.
Why it matters: Hazards and poor supervision can lead to falls and injuries that are serious for older adults.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: May 11, 2017 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 23, 2017 · F-0309
The facility did not provide the care and services each resident needed to stay as healthy and well as possible.
Why it matters: Missing needed care can lead to avoidable decline, pain, or complications for a resident.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 11, 2017 (Deficient, Provider has date of correction)
All citations in the current public record (37)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Dec 2, 2021 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Dec 2, 2021 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Dec 2, 2021 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Dec 2, 2021 | D · Potential for harm, one-off | The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. |
| Dec 2, 2021 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Dec 2, 2021 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Dec 2, 2021 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Dec 2, 2021 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Dec 2, 2021 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Dec 2, 2021 | D · Potential for harm, one-off | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Dec 2, 2021 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Dec 2, 2021 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Dec 2, 2021 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Dec 2, 2021 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Oct 11, 2018 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Oct 11, 2018 | D · Potential for harm, one-off | The facility did not honor residents' right to share a room with their spouse or a roommate of their choosing, or moved residents to a different room without written notice beforehand. |
| Oct 11, 2018 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Oct 11, 2018 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Oct 11, 2018 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Oct 11, 2018 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Oct 11, 2018 | D · Potential for harm, one-off | The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. |
| Oct 11, 2018 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Oct 11, 2018 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Oct 11, 2018 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Oct 11, 2018 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Oct 11, 2018 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 23, 2017 | ▲ K · Immediate jeopardy, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent avoidable accidents like falls. |
| Mar 23, 2017 | ▲ G · Actual harm, one-off | The facility did not provide the care and services each resident needed to stay as healthy and well as possible. |
| Mar 23, 2017 | F · Potential for harm, facility-wide | The facility did not store, cook, or serve food in a safe and clean way. |
| Mar 23, 2017 | E · Potential for harm, repeated | The facility did not provide the social services residents needed — help with things like emotional support, adjusting to the facility, connecting with resources, and planning for changes in care. |
| Mar 23, 2017 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, home-like environment, or did not let residents use their own belongings as much as possible. |
| Mar 23, 2017 | E · Potential for harm, repeated | The facility did not have an effective program to investigate, control, and prevent the spread of infections. |
| Mar 23, 2017 | E · Potential for harm, repeated | The facility did not make sure its nurse aides could actually demonstrate the skills and techniques needed to care for residents. |
| Mar 23, 2017 | D · Potential for harm, one-off | The facility did not promptly notify the resident, their doctor, and a family member when something important happened — such as an injury, a decline in health, or a room change. |
| Mar 23, 2017 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to meet residents' individual needs and preferences — for example, arranging rooms, routines, or services around what each person needs. |
| Mar 23, 2017 | D · Potential for harm, one-off | The facility did not properly care for residents needing special medical services, such as injections, ostomy care (a surgically created opening for waste), breathing tube care, respiratory treatments, foot care, or artificial limbs. |
| Mar 23, 2017 | D · Potential for harm, one-off | The facility did not train all employees on what to do in an emergency, or did not run unannounced practice drills for staff. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (12 → 14).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2017 | 11 | 2 | K ▲ |
| 2018 | 12 | 0 | D |
| 2021 | 14 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Virginia avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.75 | 3.67 | 3.95 | top 26% in Virginia; bottom 49% in the U.S. |
| Registered Nurse hours | 0.63 | 0.66 | 0.69 | top 31% in Virginia; top 44% in the U.S. |
| Weekend total nurse staffing | 3.38 | 3.21 | 3.50 | top 25% in Virginia; top 49% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.53 | 0.46 | 0.48 | top 19% in Virginia; top 29% in the U.S. |
| Total nursing staff turnover (%) | 27.0 | 48.1 | 45.8 | top 8% in Virginia; top 9% in the U.S. |
| RN turnover (%) | 46.4 | 48.2 | 42.9 | top 48% in Virginia; bottom 41% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.81, RN 0.64, weekend 3.43. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bdsheffer LLC | Organization | 5% or Greater Indirect Ownership Interest | 20% | 09/30/2010 |
| DJ Petrine LLC | Organization | 5% or Greater Indirect Ownership Interest | 48% | 09/30/2010 |
| Goodall, Lury | Individual | 5% or Greater Indirect Ownership Interest | 15% | 09/30/2010 |
| Nova Care LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 09/30/2010 |
| Stallard, Patricia | Individual | 5% or Greater Indirect Ownership Interest | 10% | 09/30/2010 |
| Tucker, David | Individual | 5% or Greater Indirect Ownership Interest | 7% | 09/30/2010 |
| Alesantrino, Joe | Individual | Corporate Officer | NOT APPLICABLE | 06/01/2019 |
| Commonwealth Care of Roanoke INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 09/30/2010 |
| Petrine, Deborah | Individual | Corporate Officer | NOT APPLICABLE | 09/09/2010 |
| Tucker, David | Individual | Corporate Officer | NOT APPLICABLE | 10/01/2010 |
| White, Brenda | Individual | W-2 Managing Employee | NOT APPLICABLE | 10/16/2020 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What do you do to prevent falls, and how do you supervise residents who are at high risk?"
- "Can you walk me through how you make sure each resident gets all the care their condition requires?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "How are residents and families included in care plan meetings, and how often do those meetings happen?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Johnson Cntr/Falcons Landing | 1.8 mi | Potomac Falls, VA | ★★★★★ | 4/5 | |
| Ashby Ponds INC | 3.5 mi | Ashburn, VA | ★★★★☆ | 3/5 | |
| Dulles Health & Rehab Center | 7.0 mi | Herndon, VA | ★★★★☆ | 3/5 | |
| Montcare at Potomac | 10.1 mi | Potomac, MD | ★★★★★ | 4/5 | |
| Fair Oaks Health & Rehabilitation | 10.3 mi | Fairfax, VA | ★☆☆☆☆ | 1/5 | |
| The Village at Rockville | 11.0 mi | Rockville, MD | ★★★☆☆ | 3/5 | |
| Shady Grove Nursing and Rehabilitation Center | 11.6 mi | Rockville, MD | ★★☆☆☆ | 1/5 | |
| Loudoun Rehabilitation and Nursing Center | 11.7 mi | Leesburg, VA | ★★☆☆☆ | 1/5 | |
| Heritage Hall-Leesburg | 12.0 mi | Leesburg, VA | ★★★★★ | 4/5 | |
| Collingswood Rehabilitation and Healthcare Center | 12.1 mi | Rockville, MD | ★★☆☆☆ | 2/5 | |
| Sterling Care Rockville Nursing | 12.4 mi | Rockville, MD | ★★★★☆ | 3/5 | |
| Fairfax Rehabilitation and Nursing Center | 12.7 mi | Fairfax, VA | ★★☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 495179.