Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Charlottesville Health & Rehabilitation Center during CMS and state inspections, most recent first.
Due to low weekend staffing, only two CNAs were available to care for 59 residents on one unit, resulting in residents not receiving showers as per their preferences. Staff prioritized essential care, providing hygiene and shortened bed baths, and ensured residents were fed and safe, but were unable to meet all resident preferences for showers.
A resident was administered Amitriptyline and Trazodone after admission when staff used the at-home medication list instead of the hospital discharge summary, resulting in unnecessary psychotropic medication use. Despite repeated requests from the resident's son and documentation by the nurse practitioner to discontinue these medications, they were only held temporarily and then restarted. Facility staff confirmed the error, and policy review showed a lack of a specific protocol for psychotropic medication use.
A review of staffing records and staff interviews revealed that only two CNAs were scheduled on a unit with 59 residents during weekend day shifts, despite the facility's assessment calling for four to five CNAs per shift. Staff confirmed that essential care was prioritized and some tasks, such as showers, were not completed due to the low staffing, though no incidents or resident complaints were documented.
A resident with multiple medical conditions and moderate cognitive impairment was discharged without the facility arranging for home health therapy services as indicated in the discharge instructions. Staff interviews and record reviews revealed a lack of documentation and follow-through in setting up these services, resulting in the resident only receiving home health therapy after a primary care provider referral post-discharge.
Staff did not follow physician discharge orders for a resident's admission, instead entering medications from the at-home list that were not included in the hospital discharge summary. Interviews with LPNs, the DON, and the regional clinical director confirmed that non-discharge medications were added, and the NP was unaware of the error. Facility policy required adherence to prescriber orders, but unfamiliarity with the discharge summary format led to the deficiency.
A resident was prescribed amitriptyline for depression without a corresponding diagnosis, and antipsychotic medications were not discontinued as requested by the resident's son. The nurse practitioner and nursing staff failed to verify the presence of a depression diagnosis in the medical record, resulting in medications being continued without proper justification or review, contrary to facility policy.
The facility did not ensure accurate and complete medical records for two residents. One resident was documented as having depression and was prescribed amitriptyline without a corresponding diagnosis, and antipsychotic medications were not discontinued as requested. Another resident's stage three pressure ulcer was inconsistently documented in progress notes and skin assessments, with discrepancies confirmed by the DON and nurse consultant.
Staff did not follow posted menus or serve meals as indicated on residents' meal tickets, resulting in multiple residents not receiving the correct foods or portion sizes, including those on specialized diets such as heart healthy and diabetic diets. Substitutions were made without documentation, and beverages were inconsistently provided. Dietary staff and management were aware of ongoing resident complaints, and facility records confirmed repeated issues with menu adherence and lack of proper dietary accommodations.
Staff did not provide milk and other beverages as listed on meal tickets, resulting in multiple residents receiving insufficient liquids with meals. Observations and interviews confirmed that milk was routinely omitted, and the hydration station meant to supply beverages was often not set up, leaving residents with only one cup of juice or coffee and no milk, despite its availability in the kitchen.
Facility staff did not consistently prepare or serve meals according to physician-ordered therapeutic and mechanically altered diets, resulting in residents on diabetic and heart healthy diets receiving incorrect foods and portions, and a resident requiring a mechanically altered diet being served improperly prepared food. Ongoing complaints from residents and documentation review confirmed repeated failures to follow prescribed dietary orders.
Facility staff did not maintain the walk-in freezer and pellet warmer in safe, working condition, resulting in a damaged freezer door with significant ice buildup and a non-functional pellet warmer. Staff and maintenance confirmed both issues had persisted for an extended period, with ongoing resident complaints about cold food and visible evidence of equipment disrepair. Documentation showed attempts to contact vendors and repair the equipment, but both remained out of service, affecting food storage and meal temperature.
Staff failed to provide two residents with meals and items according to their documented preferences, including specific entrée choices and the use of a lidded cup, despite these preferences being recorded in care plans and meal tickets. Ongoing dietary concerns were also noted in resident council meeting minutes.
A resident with severe cognitive impairment experienced a fall resulting in a skin tear, but the facility failed to notify the responsible party due to incorrect documentation. An LPN and the DON acknowledged the error, confirming the deficiency in the notification process.
The facility failed to secure a sufficient surety bond to cover the personal funds of 72 residents, with a bond amount of $165,000 against a total balance of $180,783.50. The administrator was informed, and the new business office manager identified accounts needing closure, which had not been done.
The facility staff failed to adhere to food safety and sanitation standards, including improper storage temperatures, lack of labeling and dating of food items, and inadequate dishwashing practices. The walk-in cooler was not maintaining safe temperatures, and there were no temperature logs available. Food items were not labeled or dated, and dishes were stacked while wet. Additionally, staff did not wear proper hair restraints, and sanitizer solutions were ineffective.
The facility failed to maintain adequate nurse staffing, leading to long call bell wait times and unmet resident needs. Residents and staff reported significant understaffing, particularly on weekends, with CNAs often responsible for over 20 residents each. The Director of Nursing acknowledged the staffing challenges, citing reliance on a single staffing agency and frequent call-outs due to staff fatigue.
A resident had multiple medications at their bedside without an assessment to determine their ability to self-administer. The facility's LPN was unaware of any approval for self-administration, and medications were typically kept in a locked cart. The DON stated that eligible residents are provided with a lock box, but the required assessment and interdisciplinary review were not initially conducted for this resident.
A resident with multiple health issues was moved to a different room without advance written notice to the resident or their responsible party. The admissions coordinator verbally notified the resident and left a voice message for the responsible party on the day of the move, but no written notice was provided, contrary to the facility's policy. This deficiency was acknowledged by the facility staff during the survey.
A resident with multiple mental health diagnoses was admitted to a facility without the staff incorporating the Level II PASARR recommendations into their care plan. The staff were unaware of the Level II PASARR until requested by surveyors, and the care plan lacked necessary information. The discharge planner incorrectly completed a Level I PASARR, stating no Level II evaluation was needed due to severe physical illness, despite the resident being alert and communicative.
A resident with a history of falls did not receive prescribed fall prevention devices, such as a fall mat and concave mattress, as outlined in their care plan. Despite the facility's policy on fall management, observations and staff interviews revealed these interventions were not in place, leading to a deficiency in providing a safe environment.
A resident in a LTC facility had a PRN order for lorazepam that was not limited to 14 days, as required for psychotropic medications. The order remained active without an end date, and the medication was administered on multiple occasions without proper documentation for one instance. The facility lacked a policy on limiting PRN orders for psychotropics, and the issue was confirmed by the corporate nursing consultant.
A resident requested a grilled cheese sandwich during lunch but was served a cold turkey and cheese sandwich instead. Despite repeated requests, the dietary aide did not notify the cook, assuming the cook would not want to make it. The dietary manager stated that the request should have been accommodated, and there were enough staff to prepare the sandwich. The facility administrator and DON were informed of the incident.
A resident's clinical record was incomplete, missing hospice notes and documentation since mid-April. Despite receiving hospice care, the facility failed to maintain accurate records, as required by professional standards. Interviews revealed unclear procedures for uploading hospice notes, leading to missing documentation. The issue was discussed with facility leadership, but no additional information was provided before the survey concluded.
A CNA at the facility did not receive the required 12 hours of in-service training, completing only 4.75 hours in one year without covering dementia management or care for the cognitively impaired. The facility's assessment mandates such training, but the deficiency was confirmed with no additional information provided by the administration.
The facility failed to provide necessary respiratory care and services to two residents. One resident received oxygen without a physician's order, and the equipment was not labeled with the date. Another resident's respiratory equipment was not stored properly, and the tubing was not changed routinely. Observations and interviews confirmed these deficiencies, which were contrary to the facility's policy requiring weekly changes and proper storage of equipment.
A resident with a physician order for nectar thickened liquids was served thin liquids, contrary to the prescribed diet. Staff interviews revealed that some CNAs provided regular consistency liquids based on the resident's preference and family wishes, despite the risk of aspiration. The facility's therapy director confirmed the resident was not on speech therapy caseload, and the facility administrator and DON were informed of the findings.
Facility staff failed to follow infection control practices for a resident on enhanced barrier precautions. Despite clear signage and care plan instructions, CNAs provided direct care without PPE, indicating a lack of understanding and training. Observations confirmed ongoing non-compliance with infection control protocols, as outlined by facility policy and CDC guidelines.
Facility staff did not follow posted menus for six out of ten residents, leading to discrepancies between served food items and those listed on menus and meal tickets. Issues included serving 1% milk instead of whole milk, missing items like bran muffins and oatmeal, and not providing listed items such as mixed Italian vegetables. The dietary manager cited supply issues, resident preferences, and unavailability of specific items as reasons for these discrepancies, despite the facility's policy on matching meals to individualized diet orders and preferences.
During a facility survey, it was observed that food on Unit 1 was not served at an appetizing temperature. Resident interviews and meeting minutes documented dissatisfaction with cold meals. On the day of observation, food items like spaghetti with meatballs and corn showed significant temperature loss when served. The dietary manager confirmed the lukewarm temperature, citing delays in meal service. Staff interviews revealed issues with beverage shortages and delays, with a CNA reporting running out of tea and an LPN unit manager acknowledging lengthy meal service and cold food. The facility's policy emphasized maintaining proper food temperatures and timely delivery.
A facility did not notify the responsible party of medication changes for a resident with severe cognitive impairment and a complex medical history, including Alzheimer's and hip fracture. Medication adjustments involved Celexa, Zoloft, cephalexin, Namenda, and Buspar, with no documented notifications to the family or responsible party. The DON and an LPN unit manager confirmed that notifications should have been made and documented, highlighting a communication gap regarding medication changes.
Failure to Accommodate Resident Shower Preferences Due to Low Weekend Staffing
Penalty
Summary
The facility failed to accommodate resident preferences for showers on one of its units due to low weekend staffing. Payroll Based Journal (PBJ) records and weekend schedules for March 2025 showed that only two certified nursing assistants (CNAs) were scheduled for a unit with a census of 59 residents, instead of the usual four to five CNAs per shift. Staff interviews confirmed that, as a result, showers were not provided to residents on those days. Instead, CNAs prioritized essential care, providing hygiene and shortened bed baths, and ensured residents were fed and kept safe with assistance from other nursing staff. The Director of Nursing (DON) acknowledged the staffing shortage and the absence of a staff coordinator at the time. Both the DON and a unit manager LPN confirmed that the goal is to have four CNAs per shift, but this was not achieved during the weekend in question. Staff reported that when such shortages occur, non-essential care such as showers is deprioritized. No additional information was provided by the facility prior to the exit conference.
Failure to Follow Discharge Orders Led to Unnecessary Psychotropic Medication Administration
Penalty
Summary
Facility staff failed to ensure that unnecessary psychotropic medications were not administered to a resident by using the at-home medication list for admission orders instead of following the physician-verified hospital discharge summary. As a result, the resident received Amitriptyline 10 mg and Trazodone 100 mg at bedtime, which were not prescribed upon discharge from the hospital. Multiple staff interviews confirmed that the at-home medication list was incorrectly used, and the hospital discharge summary, which should have guided medication administration, was not followed. The clinical record review revealed that the resident had a history of delirium in the hospital, which had resolved by the time of discharge. Despite this, the facility continued to monitor for delirium and administered the unnecessary psychotropic medications. The resident's son repeatedly requested that these medications be discontinued due to concerns about delirium, and the nurse practitioner documented her intent to discontinue them. However, the medications were only held temporarily and then restarted, with no evidence that the discontinuation was completed as requested. Facility documentation and policy reviews indicated that medications are to be administered according to written prescriber orders and that discharge orders from the hospital should be reviewed and approved by the attending physician. Despite these policies, the facility did not have a specific policy related to psychotropic medication use, and the process for verifying and following discharge orders was not properly implemented. This resulted in the resident receiving medications that were not part of the discharge plan, contrary to both facility policy and the expressed wishes of the resident's representative.
Insufficient CNA Staffing on Unit During Weekend Shifts
Penalty
Summary
The facility failed to provide sufficient nursing staff on one of its units during a specific weekend, as evidenced by staffing records and staff interviews. Payroll Based Journal (PBJ) data and as-worked schedules showed that only two certified nursing assistants (CNAs) were scheduled for a unit with a census of 59 residents during the day shift on both Saturday and Sunday. Staff interviews confirmed that the standard staffing expectation was four to five CNAs per shift, and both the DON and CNAs acknowledged that the unit was understaffed on those days. The CNAs reported that, due to the low staffing, they had to prioritize essential care tasks, resulting in showers not being completed, though hygiene and feeding needs were met with assistance from other nursing staff. The deficiency was further supported by statements from the administrator and unit manager, who confirmed that staffing levels did not always meet the facility's assessment, especially on weekends due to turnover and call-outs. Despite the low staffing, there were no documented incidents, grievances, or resident council concerns related to unmet needs or accidents during the period in question. Resident interviews did not reveal significant concerns, except for one resident who requested a change in shower scheduling, which was subsequently addressed. The facility's own assessment indicated that four to five CNAs per shift were needed based on census and acuity, but this standard was not met on the dates reviewed.
Failure to Arrange Home Health Therapy at Discharge
Penalty
Summary
The facility failed to ensure an appropriate discharge for one resident who required home health therapy services after being discharged following spinal fusion surgery. The resident, who had multiple diagnoses including spinal stenosis, diabetes, and scoliosis, was assessed as moderately cognitively impaired and required skilled therapy services for strength training and self-transfers. Discharge instructions indicated that the resident was to receive home health services for physical and occupational therapy upon returning home. However, there was no documentation that the facility initiated these services prior to discharge, and conflicting notes existed regarding whether the resident declined home health services. Staff interviews revealed uncertainty about whether home health was set up, and the social worker could not recall the details or confirm which agency was contacted. Further investigation showed that the resident did not receive home health services immediately upon discharge and only began receiving them after a follow-up appointment with a primary care provider, who then made the referral. The facility's discharge policy required the social service department to coordinate arrangements for home health services, but there was no evidence that this was completed as required. Additionally, there was no documentation that the physician or nurse practitioner was notified if the resident declined therapy services, nor was there evidence that Adult Protective Services was contacted to ensure the resident's safety, as per facility practice.
Failure to Follow Physician Discharge Orders on Admission
Penalty
Summary
Facility staff failed to follow physician discharge orders for one resident upon admission. Instead of adhering strictly to the hospital discharge summary, staff used the resident's at-home medication list to enter admission orders, resulting in the administration of two medications (amitriptyline and trazodone) that were not included in the discharge orders. Interviews with LPNs, the DON, and the Regional Director of Clinical Services confirmed that the at-home medication list was used in addition to the hospital discharge summary, despite facility policy requiring medications to be administered only as per written prescriber orders. The nurse practitioner was unaware of the incorrect medication entries and had intended to discontinue medications at the request of the resident's son, but this was not completed. Facility documentation review showed that the policy required patient information and orders from the discharging physician to be reviewed and approved by the attending physician at admission. However, the staff's unfamiliarity with the hospital's discharge summary format contributed to the error, and the pharmacy was involved in reviewing new medications, but the process did not prevent the addition of non-discharge medications. The deficiency was identified through clinical record review, staff interviews, and policy review, confirming that the admission process was not completed according to physician discharge orders.
Failure to Ensure Proper Physician Review of Medication Orders on Admission
Penalty
Summary
Facility staff failed to ensure that a physician or appropriate practitioner thoroughly reviewed a resident's medication regimen upon admission. Specifically, a resident was prescribed amitriptyline for depression, despite the absence of a documented diagnosis of depression or delirium in the clinical record or hospital discharge summary. The nurse practitioner noted the son's request to discontinue antipsychotic medications, including amitriptyline, trazodone, and Seroquel, and intended to discontinue them, but did not complete the discontinuation process. The medications remained active from admission until the resident's discharge. Interviews with facility staff, including the MDS Coordinator and the nurse practitioner, revealed that the diagnosis of depression was incorrectly assigned based on assumptions rather than documented evidence. The nurse practitioner acknowledged that the diagnosis was not found in the hospital records and that the nursing staff had entered the diagnosis with the medication on admission, which she did not notice when signing off on the paperwork. Facility policy required that admission information and orders be reviewed and approved by the attending physician, and that the medical plan of care be reviewed at each visit, but this process was not properly followed in this case.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two of six residents reviewed. For one resident, staff did not correctly document admission medications and linked a diagnosis of depression to the use of amitriptyline, despite no documented history of depression or delirium in the resident's records. The nurse practitioner acknowledged that the diagnosis of depression was not found in the hospital records and that the medication was continued without a corresponding diagnosis. Additionally, the resident's son requested discontinuation of antipsychotic medications, which was noted by the nurse practitioner, but the medications were not discontinued as intended. For another resident, there were inconsistencies in the documentation of a stage three pressure ulcer. While the initial skin assessment indicated the presence of the ulcer and treatments were initiated, subsequent daily skilled assessment progress notes and weekly skin assessments inconsistently documented the presence of the pressure ulcer, with some notes indicating 'No' or omitting documentation of the wound. The director of nursing and nurse consultant confirmed discrepancies in the clinical record documentation regarding the pressure ulcer.
Failure to Follow Posted Menus and Serve Prescribed Diets
Penalty
Summary
Facility staff failed to follow posted menus and serve meals as indicated, resulting in residents not receiving the foods listed on their meal tickets. Observations revealed that for both breakfast and lunch, the items served did not match the posted menus or the residents' meal tickets. For example, cranberry muffins listed for breakfast were not prepared or served, and instead, toast was substituted without documentation or use of a substitution log. Beverages, including milk, were not consistently provided with meals, and substitutions were made at the discretion of the cook without guidance or oversight. The cook admitted to making substitutions based on availability and did not maintain or reference a substitution log, as required by facility policy. During lunch service, further discrepancies were observed. The posted menu called for baked ham, carrots, scalloped potatoes, dinner rolls, and chocolate cake with chocolate frosting, but residents were served mixed vegetables, diced red potatoes instead of scalloped potatoes, yellow cake without chocolate frosting, and in some cases, no roll or milk. Residents on specialized diets, such as heart healthy or diabetic diets, did not receive the appropriate menu items or portion-controlled servings. For example, residents requiring a heart healthy diet were supposed to receive baked pork chops but were served ham instead. Diabetic residents received full portions of dessert rather than the required half portions, and when cake ran out, sherbet was substituted without documentation. Chopped meats were not prepared to consistent sizes, and dietary aides did not question discrepancies between meal tickets and what was served. Interviews with dietary staff, the registered dietician, and the activities director confirmed ongoing issues with menu adherence, lack of proper substitutions, and resident complaints about meals not matching posted menus or dietary needs. Resident council minutes and the grievance log documented repeated concerns from residents about these issues over several months. The registered dietician and activities director both acknowledged the lack of a functioning substitution log and ongoing communication problems with the contracted dietary company. Multiple residents were directly affected, including those with specific dietary orders, who did not receive meals as prescribed.
Failure to Provide Beverages Consistent with Resident Needs and Preferences
Penalty
Summary
Facility staff failed to provide beverages, specifically milk and other liquids, in quantities consistent with resident needs and preferences on both units. Observations during breakfast revealed that residents were served food without beverages on their trays, and only one cup of coffee or juice was distributed from the beverage cart. Milk, although listed on residents' meal tickets, was not provided. Staff interviews confirmed that milk was not routinely offered, with one CNA stating that only cream was provided for coffee and another indicating that milk was only given to select residents who requested it. Dietary staff admitted to omitting milk from trays unless specifically asked, despite it being listed on meal tickets. Residents interviewed confirmed they did not receive milk and only received one cup of juice with meals. Further observations during lunch service showed that, despite milk being available in the kitchen and listed on meal tickets, it was not served to residents. The activity director reported that the hydration station in the dining room, intended to provide beverages, was often not set up, resulting in residents receiving food without beverages. Resident grievances had previously been filed regarding the lack of milk with meals, but the issue persisted. The facility did not have a policy regarding beverage service.
Failure to Follow Physician-Ordered Therapeutic and Mechanically Altered Diets
Penalty
Summary
Facility staff failed to prepare and serve foods in accordance with physician-ordered therapeutic diets, affecting multiple residents across both nursing units. Observations revealed that residents on diabetic and heart healthy diets did not receive meals consistent with their prescribed dietary requirements. For example, residents on a heart healthy diet were served baked ham instead of the prescribed baked pork chop, and those on diabetic diets received full portions of cake instead of the required half portions. Additionally, when the kitchen ran out of certain menu items, substitutions were made without regard to the residents' dietary orders, and some residents did not receive all components of their meals, such as dinner rolls. Dietary aides did not question or adjust trays when discrepancies were noted, and the cook admitted to inconsistent portioning, especially in the absence of a manager. Resident council minutes and grievance logs indicated ongoing concerns and complaints from residents regarding the lack of adherence to diabetic diets and discrepancies between posted menus and actual meals served. Residents reported receiving meals with excessive carbohydrates and inappropriate portion sizes, which did not align with their dietary restrictions. The activities director corroborated these concerns, noting frequent mismatches between the menu and what was served, and described efforts to facilitate communication between residents, the dietary company, and the registered dietitian. Despite meetings and discussions, residents continued to express dissatisfaction with the dietary services provided. In a specific instance, a resident with an order for a mechanically altered diet (mechanical advanced chopped baked ham) was served ham cut into long strips rather than chopped, as required. This issue was also reflected in resident council meeting minutes, where concerns about mechanically altered diets not being provided were documented. Facility policy required that therapeutic and mechanically altered diets be prepared according to physician or dietitian orders and individualized care plans, but observations and documentation review confirmed that these standards were not consistently met.
Failure to Maintain Essential Kitchen Equipment in Safe Operating Condition
Penalty
Summary
Facility staff failed to maintain essential kitchen equipment in safe, operating condition, specifically the walk-in freezer and the pellet warmer. During an observation, the walk-in freezer door was found to be damaged and unable to close completely, resulting in significant ice buildup around the door jamb and on the floor, as well as frost accumulation on food packages near the door. The door gasket was detached at the bottom, and the maintenance director confirmed the door had been in poor condition for an extended period, with a new seal unable to resolve the issue due to the door being bent. Communication records showed that the facility had been in contact with a vendor to address the issue, but a replacement had not yet been secured. Additionally, the pellet warmer in the main kitchen was not operational during meal service, leading staff to serve food without using the pellets intended to keep meals warm. Dietary aides reported the pellet warmer had not been working, and the evening cook stated it had been out of service for about two months due to a burning smell and lack of heat. Resident council meeting minutes and grievance logs documented ongoing complaints from residents about cold food, with repeated references to the pellet warmer being out of order. The activities director and maintenance director both confirmed ongoing issues with the pellet warmer, including difficulties in obtaining the correct replacement parts and repeated failed repairs. The facility's documentation included emails and technician notes indicating persistent challenges in identifying and sourcing the necessary parts for the pellet warmer, as well as communication with vendors regarding both the freezer door and the pellet warmer. Despite these efforts, both pieces of essential kitchen equipment remained in disrepair at the time of the survey, directly impacting food storage and meal service.
Failure to Honor Resident Meal Preferences and Dietary Requests
Penalty
Summary
Facility staff failed to provide meals in accordance with resident preferences for two residents out of a sample of eight. One resident was observed receiving a lunch meal that did not match their documented meal ticket, which specified a deli sandwich and tossed salad, but instead received ham, mixed vegetables, diced red potatoes, and a roll. When questioned, the resident confirmed that the meal was not what they wanted. The facility's own policy states that menus are to be served as written unless changed in response to preference, unavailability, or special meal requirements. Another resident was observed receiving a meal that did not match their requested entrée of baked pork chop, instead receiving baked ham, and was not provided with a lidded cup as documented in their care plan. The resident confirmed that they usually receive a pork chop and prefer a lidded cup, which was not provided. Review of resident council meeting minutes revealed ongoing unresolved dietary concerns, including meal tickets not being followed and resident choices not being granted. These findings were discussed with facility leadership during the survey.
Failure to Notify Responsible Party of Resident's Fall
Penalty
Summary
The facility staff failed to notify the responsible party of a change in condition for a resident who experienced a fall with injury. The resident, who had a cognitive score indicating severe cognitive impairment, was involved in a fall incident where they attempted to get up from a wheelchair and landed on their knees, resulting in a skin tear to the left elbow. The clinical record incorrectly documented the resident as their own responsible party (RP), despite having a friend listed as the RP. During an interview, an LPN acknowledged that the physician and RP should be notified in the event of a change in condition or fall with injury. Upon reviewing the documentation, the LPN recognized the error in the notification process, as the resident was not their own RP. The Director of Nursing also reviewed the documentation and concurred that the RP should have been notified, confirming the deficiency in the notification process.
Insufficient Surety Bond for Resident Funds
Penalty
Summary
The facility staff failed to secure a sufficient surety bond to cover the personal funds of residents deposited with the facility, affecting 72 residents. On July 10, 2024, the facility provided a surety bond amounting to $165,000, which was insufficient to cover the total balance of $180,783.50 in the resident trust accounts. During an end-of-day meeting, the facility administrator was informed of this discrepancy. The business office manager, who had recently started at the facility, acknowledged that several accounts needed to be closed, but this had not yet been completed.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility staff failed to store, prepare, and serve food in accordance with professional standards for food safety, which has the potential to affect multiple residents. During a kitchen tour, it was observed that the walk-in cooler was not maintaining an appropriate temperature, with the internal thermometer reading 55 degrees Fahrenheit. The dietary manager acknowledged issues with the cooler and confirmed that the milk stored inside was at 52 degrees, which is above the safe temperature threshold. Additionally, there were no temperature logs available for any of the food storage areas, and staff were unaware of the temperature monitoring responsibilities. The facility staff also failed to label and date foods that had been opened and stored food in a manner that could lead to contamination. Items such as onions were found on the floor, and various food items were not labeled with preparation or use-by dates. Open containers of food were left uncovered, and some items were stored directly on the floor. The dietary manager confirmed that all food items should be labeled and dated to prevent food poisoning, but this practice was not consistently followed. Furthermore, the facility staff did not adhere to proper dishwashing and sanitization procedures. Dishes were observed being stacked while still wet, which could promote bacterial growth. The sanitizer solution used for cleaning food preparation areas was found to be ineffective, with no sanitizer present in the solution. Additionally, the facility staff failed to monitor and record food temperatures to ensure they were cooked and held at safe temperatures. The dietary manager was unaware of the missing temperature logs, and staff were not wearing proper hair restraints while in the kitchen, further compromising food safety.
Chronic Understaffing Leads to Resident Care Deficiencies
Penalty
Summary
The facility failed to maintain sufficient nurse staffing to ensure the safety and well-being of residents across two nursing units. Residents reported waiting over an hour for call bell responses, particularly on weekends, due to inadequate staffing. The Ombudsman and resident council expressed concerns about the dangerous staffing levels, with some residents unable to receive timely assistance for basic needs such as using the bathroom. Staff interviews corroborated these issues, with CNAs reporting that they were often responsible for over 20 residents each, making it impossible to provide necessary care, including regular showers. The facility's staffing records from June to early July 2024 revealed multiple instances where staffing levels were significantly below the required number of CNAs per unit. On several occasions, only two CNAs were available for entire shifts, far below the facility's assessment requirement of five CNAs per shift per unit. This chronic understaffing was particularly acute on weekends and during night shifts, leading to long call bell wait times and unmet resident needs. The Director of Nursing acknowledged the staffing challenges, citing reliance on a single staffing agency and frequent call-outs due to staff fatigue from working extended hours. Despite efforts to cover shifts, including management stepping in, the facility struggled to meet its staffing needs, particularly for the skilled unit with higher acuity residents. The facility's average census of 100 residents further exacerbated the staffing shortfall, impacting the quality of care provided.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility staff failed to assess and determine if a resident was safe to self-administer medications that were at the bedside. Resident #28 had multiple medications, including prescription nasal spray, sterile eye drops, and toothache cream, stored on the over bed table and bedside table in their room. The resident reported using these medications regularly, but there was no evidence in the clinical record or care plan that an assessment had been conducted to evaluate the resident's ability to self-administer these medications. During observations and interviews, it was revealed that the facility's licensed practical nurse (LPN) was unaware of any assessment or approval for the resident to self-administer medications. The LPN mentioned that medications are typically kept in a locked medication cart and administered by nurses. However, the LPN acknowledged that families sometimes bring in medications without the facility's knowledge, and these are removed when discovered. The LPN confirmed that the nasal spray was from the facility's pharmacy and removed it, along with other medications, from the resident's bedside. The facility's director of nursing (DON) stated that residents who can self-administer medications are provided with a lock box to prevent access by other residents. The facility's policy requires a safety screen assessment and interdisciplinary team review to determine eligibility for self-administration. However, this process was not initially followed for Resident #28, leading to the deficiency. The facility later conducted the necessary assessment and obtained physician orders for unsupervised self-administration of certain medications.
Failure to Provide Advance Written Notice of Room Change
Penalty
Summary
The facility staff failed to provide advance written notice of a room change for a resident, identified as Resident #77, who was part of a survey sample. The resident, who had multiple diagnoses including adult failure to thrive, deep vein thrombosis, and major depressive disorder, was assessed with moderately impaired cognitive skills. On July 1, 2024, the resident was moved to a different room without prior written notification to either the resident or the responsible party. The family member of the resident confirmed that no advance notice was given regarding the room change. The admissions coordinator admitted to notifying the resident verbally on the day of the room change and leaving a voice message for the responsible party, but no written notice was provided. The coordinator also acknowledged marking the room change notification form as if a copy had been provided, although no actual copy was given. The facility's admissions/business contract stated that residents had a right to advance notice of room changes, which was not adhered to in this case. This deficiency was discussed with the facility's administrator, director of nursing, and regional nurse consultant, but no further information was provided before the survey concluded.
Failure to Incorporate Level II PASARR Recommendations
Penalty
Summary
The facility staff failed to obtain and incorporate the recommendations from a Level II PASARR into the assessment and care plan for a resident in the survey sample. The resident, who had a Level II PASARR, was admitted to the facility with multiple diagnoses, including hemiplegia, schizoaffective disorder, and major depressive disorder. Despite these conditions, the facility staff were unaware of the Level II PASARR until it was requested by the survey team. The care plan did not address the Level II PASARR or its recommendations, and the facility's documentation did not include the necessary information. During the survey, it was discovered that the discharge planner/social services director had completed a Level I PASARR, which incorrectly indicated that no Level II evaluation was required due to a severe physical illness. However, the resident was alert and communicative, contradicting the justification for not performing a Level II PASARR. The facility's policy required that any Level II PASARR be incorporated into the care plan within five days of admission, but this was not done. The facility administrator was informed of these findings during an end-of-day meeting.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility staff failed to ensure that a resident, identified as R28, received necessary fall prevention devices, leading to a deficiency in providing a safe environment. R28, who had a history of falls, reported having several falls while at the facility and was unaware of any interventions in place to prevent future incidents. Observations confirmed the absence of a fall mat and a concave mattress, which were specified in the resident's care plan as interventions to prevent falls and injuries. The care plan, last revised on 6/7/24, indicated these interventions were necessary due to R28's impaired gait and mobility. Interviews with facility staff, including an LPN who routinely cared for R28, revealed a lack of awareness and implementation of the prescribed interventions. The LPN confirmed the absence of the fall mat and concave mattress in R28's room and expressed concern that a fall mat might pose additional risks, indicating a possible misunderstanding of the care plan requirements. The facility's Fall Management Program policy emphasizes the need for a systematic approach to fall prevention, including discussing risks and interventions with patients and incorporating them into care plans. However, the failure to implement these measures for R28 highlights a deficiency in adhering to this policy.
Failure to Limit PRN Psychotropic Medication Order
Penalty
Summary
The facility staff failed to ensure that a PRN order for the psychotropic medication lorazepam was limited to 14 days for a resident, identified as Resident #82 (R82). The order, dated 5/1/24, was for lorazepam oral concentrate 2 mg/ml to be given 1 ml by mouth every 1 hour as needed for end-of-life anxiety, but it had no end date and remained active. The medication was administered on 5/3/24, 6/30/24, and 7/2/24, but there were no nursing notes explaining the administration on 5/3/24. Notes on 6/30/24 and 7/2/24 indicated the medication was given for agitation and anxiety, respectively, with the medical doctor being aware. The clinical record review revealed that the physician did not reference the PRN lorazepam order during visits on 5/2/24, 5/15/24, and 6/2/24, despite R82 being admitted to hospice services. The corporate nursing consultant confirmed that PRN orders for psychotropics should not exceed 14 days, and the facility lacked a policy regarding this. The facility administrator and director of nursing were informed of these findings, but no additional information was provided.
Failure to Accommodate Resident Meal Preferences
Penalty
Summary
The facility staff failed to provide meal substitutions in accordance with resident preferences for one resident in a survey sample of 26 residents. On the specified date, a resident requested a grilled cheese sandwich during lunch but was served a cold turkey and cheese sandwich instead. Despite the resident's repeated requests to the dietary aide, the aide insisted that the resident had ordered the turkey sandwich and did not notify the cook of the resident's preference for a grilled cheese sandwich. The dietary manager, upon being informed of the incident, expressed that the resident's request should have been accommodated and that there were sufficient staff available to prepare the grilled cheese sandwich. The dietary aide admitted to not notifying the cook because she assumed the cook would not want to make it. The facility administrator and director of nursing were informed of these findings, but no further information or facility policy regarding food preferences was provided before the conclusion of the survey.
Incomplete Clinical Record for Hospice Care
Penalty
Summary
The facility staff failed to maintain a complete and accurate clinical record for a resident, identified as Resident #77, who was receiving hospice care. The resident's clinical record lacked recent hospice notes and documentation, which is a requirement according to accepted professional standards. Resident #77 was admitted with multiple diagnoses, including adult failure to thrive, deep vein thrombosis, insomnia, severe protein-calorie malnutrition, major depressive disorder, cancer, and gastroesophageal reflux disease. The resident was assessed with moderately impaired cognitive skills. Despite receiving hospice care since January 19, 2024, the clinical record did not include hospice notes or records of services provided since mid-April 2024. Interviews with the Director of Nursing (DON) and the medical records coordinator revealed that hospice was supposed to provide notes after each visit, which were then uploaded to the clinical record. However, the DON was unsure why the notes were missing, and the medical records coordinator indicated that the system for uploading hospice notes was unclear. The coordinator also mentioned that hospice sometimes provided notes in bulk rather than after each visit. Before the survey concluded, the medical records coordinator obtained the missing hospice notes, which included nineteen entries from hospice nurses, social workers, and a spiritual counselor, dated from April 15, 2024, to June 21, 2024. This deficiency was discussed with the administrator, DON, and regional nurse consultant, but no further information was provided before the survey ended.
Inadequate In-Service Training for CNA
Penalty
Summary
The facility staff failed to ensure that a certified nursing assistant (CNA) received the required 12 hours of in-service training per year. Specifically, CNA #8, who was hired on August 30, 2022, only completed 4.75 hours of training from August 30, 2022, to August 30, 2023. The training did not include essential topics such as dementia management or care for the cognitively impaired. Additionally, for the year 2024, CNA #8 had only completed 1.5 hours of training, which covered HIPAA, infection control, and bloodborne pathogens. The facility's assessment indicated that it provides care for residents with cognitive impairments and requires in-service training for nurse aides to include dementia management and resident abuse prevention. The facility's failure to provide the necessary training was confirmed during a review with the facility administrator and corporate nurse consultant, who did not provide any additional information to address the deficiency.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility staff failed to provide necessary respiratory care and services to two residents, leading to deficiencies in their care. For Resident #84, the staff administered oxygen without obtaining a physician's order and failed to label the oxygen tubing with the date. The resident, who was admitted with diagnoses including congestive heart failure and pressure ulcers, was observed receiving oxygen therapy without a corresponding physician order. Interviews with the LPN and the Director of Nursing confirmed the absence of a physician order for the oxygen therapy being administered to Resident #84. In the case of Resident #28, the facility staff did not store respiratory equipment properly to prevent contamination and failed to change the tubing on a routine basis. Observations revealed that the nebulizer mask and tubing had not been changed since 6/25/24, and the oxygen tubing was dated 6/1/24. The oxygen nasal cannula was found hanging open to air, contrary to the facility's policy that requires such equipment to be stored in a labeled, dated bag. Interviews with an LPN confirmed these findings and highlighted that the equipment was not being changed weekly as required by the facility's policy. The facility's policy titled 'Patient Care Equipment' mandates that oxygen humidifier bottles, cannulas/masks, and tubing are changed weekly, and that tubing not in use should be kept in a labeled, dated bag. However, the facility failed to adhere to these standards, as evidenced by the observations and interviews conducted during the survey. The Director of Nursing confirmed that the respiratory equipment setup is supposed to be changed weekly, yet the facility did not provide any additional information or corrective actions during the exit conference.
Failure to Provide Prescribed Thickened Liquids
Penalty
Summary
The facility staff failed to provide a therapeutic diet in accordance with physician orders for a resident who had a physician order for nectar thickened liquids (NTL). During observations, the resident was served thin liquids, including apple juice and water, which were not in compliance with the prescribed NTL. The meal ticket on the resident's tray indicated the requirement for NTL, but the staff, including a CNA, provided regular consistency liquids, citing the resident's preference and family wishes as reasons for the deviation. Interviews with staff revealed a lack of adherence to the physician's orders, with some staff members believing the resident could handle thin liquids despite the risk of aspiration. The therapy director confirmed that the resident had not been on speech therapy caseload and acknowledged the risk of aspiration from serving thin liquids. The facility administrator and director of nursing were informed of these findings, but no additional information was provided regarding corrective actions.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility staff failed to adhere to infection control practices for a resident on enhanced barrier precautions. The resident, who had been admitted with diagnoses including Stage 3 pressure ulcers and a cutaneous abscess, was observed receiving direct care from two certified nursing assistants (CNAs) without the required personal protective equipment (PPE). Despite signage indicating the need for enhanced barrier precautions, the CNAs assisted the resident with bathing, dressing, transferring, and changing bed linens without wearing PPE. Interviews with the CNAs revealed confusion about the signage and the requirements for wearing protective clothing, indicating a lack of understanding and training regarding infection control protocols. Further observations confirmed that the CNAs continued to provide direct care without PPE, even after the issue was initially identified. The facility's documentation and the resident's care plan both specified the need for enhanced barrier precautions, which were not followed. The Director of Nursing confirmed the oversight during a subsequent observation. The facility's policy and CDC guidelines clearly outlined the necessity of gown and gloves during high-contact care activities, especially for residents with wounds, yet these protocols were not implemented, leading to the deficiency.
Menu Compliance Issues Due to Supply and Preference Discrepancies
Penalty
Summary
The facility staff failed to follow posted menus for six out of ten residents in the survey sample, resulting in discrepancies between the food items served and those listed on the menus and meal tickets. Residents #1, #2, #3, #5, #6, and #10 were not provided with the correct food items as per the posted menu and meal tickets. Examples of discrepancies included serving 1% milk instead of whole milk, missing food items like bran muffins and oatmeal, and not providing items listed on the menu such as mixed Italian vegetables and whole milk during lunch service on 4/9/24. During interviews with residents and staff, concerns were raised about the inconsistency between the food served and the menu listings. The dietary manager explained reasons for the discrepancies, such as issues with milk supply, resident preferences for certain food items like sausage, and unavailability of specific food items like mixed Italian vegetables. Despite the facility's policy emphasizing the importance of meals matching individualized diet orders and preferences, the observations revealed a failure to adhere to the posted menus and meal tickets, leading to the deficiency in menu compliance.
Temperature and Timeliness Issues in Meal Service on Unit 1
Penalty
Summary
During a facility survey, it was observed that food was not served at an appetizing temperature on Unit 1. Resident interviews revealed concerns about cold meals, with the resident council president stating that food served in rooms was usually cold. Meeting minutes from January to March documented residents expressing dissatisfaction with the taste and temperature of the food. On the day of observation, food temperatures on the steam table were recorded, with items like spaghetti with meatballs and corn showing significant temperature loss when served to residents. The dietary manager confirmed the lukewarm temperature of the food, noting delays in serving meals after delivery to the floor. Further interviews with staff revealed issues with beverage shortages and delays in meal service. A certified nurses' aide reported running out of tea and having to fetch more from the kitchen, while the licensed practical nurse unit manager acknowledged the lengthy meal service and cold food served during lunch. The facility's policy on meal distribution emphasized the importance of maintaining proper food temperatures, preventing contamination, and ensuring timely delivery to residents.
Communication Lapse in Medication Changes for Cognitively Impaired Resident
Penalty
Summary
The facility failed to notify the responsible party of medication changes for Resident #7, who had multiple medication adjustments without any communication to their family or responsible party. Resident #7 had a complex medical history including diagnoses of hip fracture, Alzheimer's, traumatic brain dysfunction, hypothyroidism, anemia, osteoporosis, anxiety, depression, seizures, and protein-calorie malnutrition. Despite being assessed with severely impaired cognitive skills for daily decision making, Resident #7 experienced medication changes including Celexa being increased and then discontinued, Zoloft being initiated and dose-adjusted, antibiotic cephalexin prescribed, Namenda and Buspar doses increased, with no documented notifications to the responsible party in the clinical record. The Director of Nursing (DON) and a Licensed Practical Nurse unit manager acknowledged during interviews that notifications regarding medication changes should have been made to Resident #7's family or responsible party. The DON confirmed the lack of notifications in the clinical record and emphasized the expectation for staff to inform families about changes in condition or treatment, including medication adjustments. LPN #2 also acknowledged that any notifications should have been documented in Resident #7's clinical notes, highlighting a gap in communication regarding medication changes for the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 71 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Charlottesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Our Lady Of Peace Inc | 1 mi | ★★★★★ | 15 | 0 |
| The Laurels Of Charlottesville | 1.1 mi | ★★★★★ | 0 | 0 |
| Monroe Health & Rehab Center | 1.3 mi | ★★★★★ | 20 | 0 |
| Colonnades Health Care Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Cedars Healthcare Center | 2.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Charlottesville Health & Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.