Hearth Record

Stafford Hospital, LLC

An acute care hospital in Stafford, Virginia 22554

101 Hospital Center Boulevard, Stafford, Virginia 22554. (540) 741-9000.

CMS’s own record, on Care Compare

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The short answer

Record last released by CMS on Oct 20, 2026.

The last 24 months 1 deficiency in 1 month of the last 36. Last cited Oct 2024. Most serious: Standard-level. Every month

Each figure’s source sits beside it, in its section below.

What these words mean3
Star ratings
CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
Inspection (survey)
A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
Deficiency, citation, violation
What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.

What did inspectors find?

The last inspection on record was on Oct 29, 2024: a complaint inspection.

1 deficiency cited in the last three years.

Source:

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

When those deficiencies happened

1 deficiency in 1 month of the last 36. Last cited Oct 2024. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.

1 deficiency by month over the last 3 years. Each cell is one month.
JanFebMarAprMayJunJulAugSepOctNovDec
2023 Dec
2024 JanFebMarAprMayJunJulAugSepOctNovDec
2025 JanFebMarAprMayJunJulAugSepOctNovDec
2026 JanFebMarAprMayJunJulAugSepOctNov

Hover or focus a month to read it.

No visit on record Visited, nothing cited A stronger orange is more serious, on its source’s own levels, read onto four bands: from the least serious it publishes to the most
Source:

Hearth Record drew this from the dates and levels in the source’s own records.

Each deficiency, as cited

Rule titles as CMS’s inspectors cite them, set in sentence case.

Source:

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

Oct 29, 2024: complaint inspection1 deficiency

  • Qualified Emergency Services Personnel

    The inspectors’ words, 966 words

    “QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 49355 Based on interviews, medical record review and facility document review, it was determined the facility failed to assess and then reassess a patient’s pain level and vitals in accordance with facility policy and procedure for one (1) out of three (3) patient’s medical records reviewed (Patient #2). Findings: A review of the medical record for Patient #2 on October 29, 2024, revealed Patient #2 presented to the ED on September 27, 2024, at 7:55 PM with a chief complaint of left knee and right hip pain while experiencing a sickle cell crisis. The Patient was triaged at 8:13 PM as an ESI three (3). Vital signs were documented but there was no documentation of an initial pain assessment. The patient was returned to the ED waiting room and was not roomed until 11:27 PM. There is no documentation that Patient #2 was ever reassessed while in the waiting room or at the time the patient was placed in an ED room. Patient #2’s first pain assessment was documented on September 28, 2024, at 1:16 AM, over five (5) hours after the patient was triaged. The patient’s pain was assessed as “severe” and the patient was administered Tylenol (pain reliever) at 1:16 AM and Toradol (nonsteroidal anti-inflammatory drug used to treat moderate to severe pain - drugs.com) at 1:18 AM for the pain. During an interview on October 29, 2024, at 1:57 PM, Staff Member #6 indicated that it is the expectation of the triage nurse to reassess a patient identified as an ESI 3 every two (2) hours for vitals and pain while in the ED waiting room. If the patient receives pain medication once in a room, the patient’s pain should be reassessed every hour. During an interview on October 29, 2024, at 2:12 PM, Staff Member #10 indicated that it is the expectation that patients waiting in the ED waiting room be reassessed for vitals and pain every two (2) hours, if the patient has been assigned a ESI level of three (3). Staff Member #10 indicated that any patient that presents to the ED should initially be assessed on a pain scale of one (1) to ten (10) or “mild to severe”. Once a patient is roomed, the pain should be reassessed at that time. The Staff Member further indicated that once given pain medications, the patients should be reassessed for pain every thirty (30) to sixty (60) minutes. A review of the facility’s policy, “Emergency Care and Treatment,” with a revision date of January, 2019, reads, in part: ...”Triage ... 2. Triage Assessment: ... b. ... The triage assessment and patient Emergency Severity Index (ESI) are assigned by an RN. ... c. The triage assessment consists of: 1. A focused history and assessment of the presenting complaint; 2. Pertinent psychosocial, surgical, and medical history.... ... e. Once the triage assessment is competed, the nurse assigns an ESI level.... The ESI level determines the priority of care.... ... f. Patients who remain in the waiting area or triage area after initial assessment and prior to admission to a treatment area are re-evaluated consistent with the ESI level assigned to the patient. Patients are re-evaluated by a nurse, paramedic, or EMT [emergency medical technician]. The guidelines for completion of re-evaluation are within the following time frames. ... 3. ESI Level 3: Every 2 hours.... The nurse, paramedic or EMT will record the patient’s vital signs and interview the patient to determine if there is a change in the patient’s clinical condition. The interview consists of ascertaining if the patient reports feeling, [sic] better, worse or the same and alerts the provider. If the vital signs are determined to be outside of the normal range or if there is a change in the patient’s clinical condition, the nurse, paramedic, or EMT will notify the triage nurse.... ... 3. Triage ESI Levels: Definitions: a. Patients are triaged according to 5 levels: ... 3. ESI LEVEL 3 (NON-URGENT): Any illness or injury which can be delayed 4 to 6 hours before medical intervention, without deterioration in the patient’s condition. ... Placement in an Emergency Treatment Room ... Assessment in the Treatment Area 1. ED admission assessment: a. All patients are assessed by a registered nurse and physician upon arrival to the ED from the Triage Area.... b. Nursing assessments are focused on the patient’s presenting complaint.... ... d. Nursing assessments are documented in the medical record.... A review of the facility’s policy, “Pain Management,” with a revision date of August, 2022, reads, in part: ... Pain Screening and Assessment 1. All patients will be screened for the presence of pain or history of persistent pain during emergency department visit, upon initial admission, after any known pain-producing event, and at unit standard intervals.... 2. If the pain screening indicates the presence of pain, a comprehensive pain assessment will be completed to evaluate the level of pain including the origin/cause, location, duration, intensity, aggravating factors, alleviating factors, effects of pain, and whether current pain regime is effective.... 3. The pain assessment is based on patient self-report and/or behavioral observation tools appropriate for the patient’s age, condition and/or identified needs. The pain assessment tools available are used to categorize pain levels as Mild, Moderate, Severe: ... g. Numerical Rating Scale, 0-10 with faces. ... Pain Reassessment 1. Reassessment to evaluate the patient’s response to a PRN [as needed] pain-relieving intervention will be completed within 60 minutes after medication administration.... Reassessment includes monitoring progress toward pain management goal.... ... 3. Documentation will include the pain intensity assessment and response to pain intervention.”

    Rule A1112. Standard-level. From a complaint.

The one inspection in the last three years
Inspections on record
DateVisitWhat the record says
Oct 29, 2024Complaint inspection1 deficiency cited

How do patients fare?

  • CMS’s overall for it is 4 of 5.
  • Of the measures behind its , CMS counts against the national value: mortality, 0 better and 0 worse of 6; safety of care, 1 better and 0 worse of 3; readmission, 0 better and 1 worse of 6.
  • Patients rate it 3 of 5 in CMS’s patient survey (814 surveys completed, Oct 1, 2024 to Sep 30, 2025): 71% rated it 9 or 10 out of 10, and 70% would definitely recommend it.
  • Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): surgical site infections after colon surgery, no different than national benchmark; C. diff infections, better than the national benchmark.
  • CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
  • Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 11.8%, heart failure 11.7%, pneumonia 12.9%, COPD 8.3%, stroke 11.3%. CMS gives no comparison with the national rate for them in this release.
  • Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 14.2%, heart failure 21.1%, pneumonia 18.6%, COPD 20.2%. CMS gives no comparison with the national rate for them in this release.
  • After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
  • Emergency department patients spent a median of 179 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 3% left before being seen.
  • 67% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
  • Medicare’s spending per patient here is 0.87 times the national median (Jan 1, 2024 to Dec 31, 2024).
Source:

CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.

CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.

Ratings and measures, as published
MeasureRating
Overall ratingCMS’s overall hospital quality star rating, 1 to 54 of 5
Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 53 of 5

Is it certified, and in good standing?

  • Medicare-certified acute care hospital since Mar 18, 2009.
  • Ownership: voluntary non-profit - private.
  • It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
  • No deficiency on record in the last three years.
  • Voluntary non-profit - Private.
Source:

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

Has it been penalized?

  • CMS doesn’t publish fines or other penalties for hospitals.
  • Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
  • 1 deficiency cited in the last three years came from an inspection that included a complaint investigation.
Source:

CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

What do patients say about their care?

  • CMS doesn’t publish staffing levels for hospitals.
  • In CMS’s patient survey, patients rate how well its nurses communicated 3 of 5.
  • 90% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
Source:

CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.

Who owns it?

  • Medicorp Health System owns 100% directly since Jan 21, 2010.
  • Medicorp Health System runs it.
  • 20 owners or officers are people: Martin Wilder (corporate director); Kimberly Young (corporate director); Chetan B Pai (corporate director); Reggie Pearson (corporate director); Reggie Pearson (managing employee (on the payroll)); William Mcdaniel (corporate director); Summer Hughes (corporate director); Sarah Ogle (corporate officer); Bruce Davis (corporate director); Christopher D Newman (corporate officer); Christopher D Newman (runs it (operational or managerial control)); Lauren Blalock (corporate officer); Alda White (corporate director); Dermaine Lewis (corporate director); Catherine Wack (corporate director); Margaret Hardy (corporate director); Agostino Visioni (corporate director); Nicholas Cadwallender (corporate director); Howard Owen (corporate director); Thomas Mathews (corporate officer).
  • CMS’s Provider of Services file records 1 change of ownership.
  • No private-equity firm among the owners CMS lists.
  • No real-estate investment trust among the owners CMS lists.
Source:

CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

Organisations CMS lists
OrganisationRoleShareSince
Medicorp Health SystemOwns 5% or more directly100%Jan 21, 2010
Medicorp Health SystemRuns it (operational or managerial control)100%Jan 21, 2010

How does it compare nearby?

  • No other hospital CMS lists is in Stafford County.
Source:

CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.

What the record doesn’t say

  • CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
  • Only complaints that led to a citation appear; complaints that didn’t aren’t published.
  • Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
  • QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
  • CMS doesn’t publish staffing levels for hospitals.
  • In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.

Sources

If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.

Source:

This copy of the record was made on Nov 5, 2026.

From the hospital

The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.

Replies

None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.

Paid listing

None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.

How to read a record

Four things every record does, shown on an example record made up for this guide.

An example record, made up for this guide

An example nursing home

Made up for this guide: no real place is shown

Not fully inspected in over two years (CMS flag)

11 health citations at the latest inspection cycle

The state average is 14.3.

Source:

CMS, State and US Averages and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

From the homeNone yet. Replies and paid listings aren’t open, and when they open they will sit here, below the record.

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