Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Our Lady Of Peace Inc during CMS and state inspections, most recent first.
Improper Dumpster Coverage: The facility failed to keep one dumpster fully covered. During observation, the dumpster had no cover, and the two-piece lid did not fully close the top, leaving openings to air. The DM stated the dumpster was emptied daily and had not been closed after morning emptying, and that dish washing staff were responsible for closing it. Facility policy required garbage containers to be pest proof with tightly fitting lids.
A facility failed to develop or carry out complete care plans for multiple residents. One resident with malnutrition and significant weight loss had no care plan for nutrition or weight loss despite ongoing weight monitoring, supplements, and medication orders. Another resident’s palm pillow for contracture was not in place during observation, a hospice resident’s life enrichment plan was not implemented consistently, a resident with dementia and behavioral disturbance had only a vague cognitive impairment care plan despite aggression and refusal of care, and another resident on Eliquis had no anticoagulant-related care plan.
Failure to Provide Person-Centered Activities: A resident with dementia was frequently observed sitting or moving around in a wheelchair without meaningful engagement, while staff passed by or only briefly interacted with him. His care plan and MDS identified preferences for outdoor time, reading, music, group activities, and religious services, but activity records showed little participation beyond limited one-on-one attempts on select days. The LEC stated she was unaware of the resident’s assessed religious preference and did not provide evidence of a dementia-specific engagement program.
A facility failed to provide person-centered dementia care for two residents with severe cognitive impairment and behavioral symptoms. One resident was repeatedly observed sitting unattended in a wheelchair in hallways and common areas without meaningful engagement, while records showed combative behavior, wandering, and agitation without assessment of triggers or root causes. Another resident had documented physical aggression, refusal of care and meds, and resistance to staff, but the record lacked evidence of assessment of behavioral triggers or individualized interventions beyond a brief impaired cognition focus in the care plan.
Unsanitary food storage, prep, and serving practices were observed in the main kitchen and a satellite kitchen. Raw meat was left uncovered, opened meat and frozen vegetables were not dated, and the kitchen floor and appliance knobs were dirty with food particles. In the satellite kitchen, a dietary aide wore the same gloves while touching multiple contaminated surfaces and then handled sandwiches and a sweet potato without changing gloves or washing hands.
A resident with a urinary catheter was observed in a wheelchair in the hall and later in the day room with the catheter bag visible and containing urine. An LPN stated the bag should not be visible to others for privacy reasons, and the facility did not provide a catheter policy.
Failure to Obtain Education and Consent for Antipsychotic Initiation: The facility failed to document resident/RR education and informed consent before starting Seroquel for a resident with dementia and behavioral disturbance. The MAR showed the antipsychotic was administered as ordered, but the record lacked evidence that the resident or RR was informed of the risks and benefits or alternatives before initiation. An LPN stated nursing staff monitor behaviors when a new antipsychotic is ordered, and the DON later produced a consent form dated after the medication had already been started.
A resident’s quarterly MDS was coded in Section P as having a restraint, but observations showed the resident did not have a restraint. The HSA stated the restraint entry was an error, and the ED and DON were notified.
Failure to update comprehensive care plans for a fall and oxygen use. Two residents had care plans that were not revised to reflect a fall without injury and a new oxygen order. Staff interviews showed an LPN believed care plans should be revised after a fall, while the MDS Coordinator stated care plans should be updated when a nurse takes an order that belongs in the plan, including oxygen administration.
An LPN directed a CNA to administer medications to a resident, and the CNA complied by giving metoprolol, a multivitamin, and Buspar. The RN supervisor witnessed the exchange, and both staff later acknowledged the task was outside the CNA's scope of practice and not within professional standards. The resident's record did not document the incident, and the facility stated the resident had no adverse effects.
A resident with a contracture had a physician-ordered left-hand palm pillow scheduled for daytime use, but staff observed the resident clinching the left fist without the palm pillow in place. An LPN said she believed CNAs applied the device, and no facility policy on palm pillows was provided.
A resident fell and did not sustain injury, but the care plan and nursing notes did not show that staff addressed or implemented any intervention to prevent future falls. The resident fell again later and again did not sustain injury. An LPN stated that an intervention should be implemented after a fall for the resident’s safety and well-being, and the facility policy called for evaluating falls and implementing interventions to prevent reoccurrence.
Respiratory care was not provided as ordered for two residents. One resident received oxygen from a concentrator set below the ordered flow rate, and the care plan did not address oxygen administration. Another resident’s oxygen tubing and nasal cannula were observed hanging over the concentrator and resting against it without covering, and an LPN stated the tubing should not be left out.
Bed Rail Risks and Consent Not Reviewed: A resident had a physician order for a grab bar/bed rail to assist with pain, transfers, and repositioning, but the record did not show that the resident or representative was informed of the risks and benefits or that consent was obtained. The resident was observed in bed with the grab bar in an upright position, and an LPN stated residents should be made aware of the risks and benefits of bed rails.
An LPN failed to follow the facility’s infection control procedure when disinfecting a resident-dedicated glucometer after blood glucose monitoring. The LPN used an alcohol swab and allowed it to air dry, while the DON stated the meter should be wiped with approved disinfecting wipes such as Sani-wipes or Clorox wipes and not alcohol. The manufacturer instructions listed validated bleach-based disinfecting wipes for the meter.
Improper Dumpster Coverage
Penalty
Summary
The facility failed to properly dispose of garbage and refuse in one of one facility dumpster. During observation, the dumpster did not have a cover over it, and when the Director of Dining Services attempted to close the two-piece lid, the pieces did not cover the entire top of the dumpster, leaving multiple areas open to air. The Director of Maintenance stated the dumpster was emptied every day and had not been closed since it was emptied earlier that morning. He also stated that dish washing staff were responsible for making sure the lid was closed after the dumpster was emptied each morning, and he acknowledged that the dumpster was not completely covered with the current lid. The facility policy reviewed stated that garbage containers should be leakproof, pest proof, and easily cleaned, with lids that fit tightly, and that appropriate control measures should be used to eliminate insects and rodents.
Incomplete Care Planning and Failure to Implement Resident Care Plans
Penalty
Summary
The facility staff failed to develop and/or implement comprehensive care plans for five residents. For one resident with protein-calorie malnutrition, dementia, and bariatric surgery status, the comprehensive care plan did not include a focus, goal, or interventions for nutritional needs or weight loss despite documented weight loss over time and physician orders for weekly weights, oral supplements, lab work, and dexamethasone for weight loss. Progress notes documented repeated weight warnings, declining weights, and discussion among staff, the NP, and the RP about weight loss and supplements, but the care plan itself did not reflect those needs. For another resident, the care plan directed staff to apply a left-hand palm pillow, and a physician order required the palm pillow to be applied in the morning and removed in the evening for a contracture. During observations, the resident was seen clenching the left fist with no palm pillow in place. Staff interviews indicated that nurses and CNAs were responsible for following the care plan, but the device was not observed in use as planned. The facility also did not implement the Life Enrichment care plan for a resident followed by hospice who was observed repeatedly sitting alone in a wheelchair in hallways and common areas without meaningful engagement. Staff passed by the resident on multiple occasions, and although some staff spoke to him, they did not consistently reposition him or engage him in activity. The resident’s activity calendars showed participation only on Mondays and Fridays, with no documented activities on other days, despite the care plan stating that staff would invite and escort him to activities and encourage family participation. In addition, the facility did not develop a care plan for a resident with dementia with behavioral disturbance and severe memory impairment. The resident’s progress notes documented resistance to care, refusal of medications, physical aggression, verbal aggression, and attempts to hurt staff, but the record did not show assessment of the root causes, triggers, or other factors related to the dementia diagnosis. The care plan only listed impaired cognitive function without interventions or additional information. The facility also failed to develop a care plan for another resident receiving Eliquis 5 mg twice daily, and the comprehensive care plan contained no information related to the anticoagulant medication.
Failure to Provide Person-Centered Activities
Penalty
Summary
The facility failed to provide person-centered activities based on Resident #18’s comprehensive assessment and stated preferences. The resident’s annual MDS identified high-importance activities including going outside when the weather is good, having books, newspapers, and magazines to read, listening to music, doing things with groups, and participating in religious services. His care plan also directed staff to invite and escort him outside when weather permitted and to assist him to activity functions, and a quarterly life enrichment note stated he would participate in music entertainment, small groups, and outdoor visits. During observations on 3/16/26, 3/17/26, and 3/18/26, R18 was frequently found in his wheelchair in hallways, alcoves, and the living room without meaningful engagement. He was observed leaning forward grasping his ankle, self-propelling toward the biohazard room door, sitting unsuccessfully in an alcove trying to move into the hallway, and remaining in the living room without participating in any activity or attending to the television. Staff members, including the DON, passed by him on multiple occasions, and while some spoke to him or repositioned him, they did not consistently engage him in activities or redirect him into meaningful participation. He was also observed touching an activity board briefly, then wheeling around the living room and coming into contact with other residents and their chairs. The activity calendars for February and March 2026 showed no documented activity participation on any days except Mondays and Fridays, when one-on-one activities were attempted. On 3/18/26, the facility’s activities calendar advertised a Hymns and Devotions activity, but the Life Enrichment Director stated she was not aware of R18’s assessed preference for religious activities and did not provide evidence of a dementia-related program of engagement or activities for him. She stated he was more of a one-on-one person, liked music entertainment, and sometimes went outside when staff were available, but the record did not show consistent provision of activities aligned with his assessed preferences.
Failure to Provide Individualized Dementia Care and Behavioral Support
Penalty
Summary
The facility failed to provide care and services to promote the highest level of wellbeing for residents with dementia, including person-centered care and individualized support for behavioral symptoms. For one resident with diagnoses including dementia and hallucinations, the most recent MDS coded severe short- and long-term memory problems. During multiple observations, the resident was seen sitting in a wheelchair in hallways, alcoves, and common areas without meaningful engagement, including times when staff passed by without assisting, repositioning, or engaging him in activity. He was also observed attempting to propel his wheelchair, touching doors and equipment, and moving around other residents without staff intervention beyond brief repositioning or verbal contact. The resident’s record included progress notes documenting combative behavior, yelling for help, going into other residents’ rooms, threatening to hit residents, hitting walls and doors, pushing another resident’s wheelchair, banging on doors and walls, and being combative during dressing and brief care. The clinical record did not show assessment of the root causes of these behaviors, triggers, or other factors related to the dementia diagnosis. The care plan identified impaired cognition/memory and wandering risk, with general interventions such as explaining care in simple terms, reassurance, assessing for distress, and providing safe surroundings, but it did not include interventions for de-escalating outbursts or engaging the resident in meaningful activities. For another resident with dementia with behavioral disturbance, the most recent MDS coded severe short- and long-term memory problems. The progress notes documented resistance to care, hypervigilance, attempts to stand or walk without assistance, physical aggression toward staff, refusal of medications, and grabbing staff by the hair and twisting a finger. The clinical record did not reveal assessment of the root causes of the behaviors, triggers, or other factors related to the dementia diagnosis. The care plan listed impaired cognitive function but contained no interventions or additional information. Interviews with facility leadership described person-centered dementia care, individualized activities, and care plan-based symptom management, but no evidence was provided of a process for assessing behavioral triggers or documenting individualized psychosocial interventions for these residents.
Unsanitary food storage, preparation, and serving practices
Penalty
Summary
Food was not prepared, stored, and served in a sanitary manner in the main facility kitchen and in one satellite kitchen. In the main kitchen on 3/17/26, surveyors observed a walk-in refrigerator with two raw slabs of meat uncovered on a sheet pan. The same refrigerator contained a 5-pound roll of ground beef that was open but not dated, and the walk-in freezer contained four open bags of spinach and other vegetables that also had no open date. The Dining Services Director stated the ground beef should have been dated, but the frozen vegetables did not need a date because frozen foods did not require an open date. The observation continued in the food preparation area, where the floors under and around appliances were slick and sticky and contained a large amount of dark food particles. The stove and large soup kettle knobs were sticky and had food particles on them. In the satellite kitchen, a dietary aide wore gloves while touching drawer handles, serving utensils, appliance handles, the countertop, and the steam table surface, then used the same gloves to cut two sandwiches into quarters and handle all pieces, and to slice a sweet potato in half and handle the halves. The Dining Services Director stated the aide should have removed her gloves and washed her hands between touching the potentially contaminated surfaces and the food to prevent contamination and cross contamination.
Visible Urinary Catheter Bag
Penalty
Summary
The facility failed to maintain dignity for one resident with a urinary catheter. The resident had a physician's order dated 2/13/26 for a urinary catheter. On 3/18/26 at 8:38 a.m., the resident was observed in a wheelchair in the hall with the urinary catheter bag visible and containing urine. On 3/18/26 at 10:53 a.m., the resident was again observed in the day room with the urinary catheter bag visible and containing urine. During an interview on 3/18/26 at 2:39 p.m., an LPN stated that a urinary catheter bag should not be visible for everyone to see because of privacy reasons. The Executive Director and DON were informed of the findings on 3/18/26 at 5:25 p.m., and the facility did not provide a policy regarding urinary catheters.
Failure to Obtain Education and Consent for Antipsychotic Initiation
Penalty
Summary
The facility failed to meet education and consent requirements for the initiation of Seroquel for one resident with unspecified dementia and other behavioral disturbance. A review of the clinical record showed an order written on 12/5/25 for Seroquel 25 mg by mouth in the evening, and the resident received the medication as ordered on the December 2025, January 2026, February 2026, and March 2026 MARs. However, the record did not contain evidence that the resident or the resident representative was educated on the risks and benefits of Seroquel, alternatives to treatment, or provided informed consent before the medication was started. During interview, an LPN stated that nursing staff monitor residents’ mood and behaviors when a new antipsychotic order is given, but she had not educated the family or obtained consent for initiation of an antipsychotic. The DON stated she was aware the resident had been started on Seroquel and provided evidence that the resident representative was educated on the risks and benefits and gave consent, but the consent form was dated 2/11/26. The facility policy reviewed did not include information related to resident or resident representative education on risks and benefits, alternatives to therapy, or informed consent prior to initiation of antipsychotic therapy.
Inaccurate MDS Coding for Restraints
Penalty
Summary
The facility staff failed to maintain an accurate MDS assessment for Resident #5. The resident’s quarterly MDS assessment with an assessment reference date of 2/17/26 was coded in Section P, Restraints and Alarms, as having a restraint. However, on 3/17/26 at 2:06 p.m. and again on 3/18/26 at 7:40 a.m., the resident was observed and did not have a restraint. During an interview on 3/18/26 at 12:09 p.m., the Health Services Administrator stated the physical restraint coded on the MDS was an entry error. The Executive Director and DON were informed of the findings on 3/18/26 at 5:25 p.m.
Failure to Update Comprehensive Care Plans for Fall and Oxygen Use
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for two residents. For one resident, the clinical record showed a fall on 12/21/25 that did not result in injury, but the comprehensive care plan initiated on 5/29/25 did not show that it had been reviewed or revised to address the fall. During interview, an LPN stated that the care plan is a pathway to keeping residents healthier and preventing negative events, and that it should be reviewed and revised after a fall. The facility policy titled, Comprehensive Person-Centered Care Planning, stated the care planning/interdisciplinary team is responsible for reviewing and updating care plans when there has been a significant change in the resident's condition. For another resident, staff failed to revise the comprehensive care plan to include oxygen use. The resident was observed in bed on multiple occasions receiving oxygen via nasal device from a concentrator set just below 2 liters per minute. The provider's order dated 2/25/26 directed oxygen at 3.5 L/min via nasal cannula, but the comprehensive care plan dated 6/23/25 did not include any information related to oxygen administration. An LPN stated floor nurses do not update care plans or make changes on them, while the MDS Coordinator stated care plans should be updated by the nurse who takes an order for something that should be included and that the resident's care plan should include oxygen administration.
Unlicensed staff administered resident medications
Penalty
Summary
The facility failed to follow professional standards of practice when an LPN directed a CNA to administer medications to Resident #17, and the CNA complied. On 1/7/26, the LPN was overheard by the RN supervisor telling the CNA to give medications to the resident and was witnessed handing a medication cup to the CNA. The medications involved were metoprolol, a multivitamin, and Buspar. The LPN later stated she asked the CNA to give the medications because she was busy administering medications to other residents and had been unable to give the resident's medications earlier due to refusal when the resident was sleeping, spitting out medications, and throwing a shoe at staff while saying no. The CNA stated she took the medications to the resident and offered them to him, and the resident took them. The resident's clinical record did not contain information about unlicensed personnel administering medications, and the facility stated the resident was assessed by the provider just hours later and had no adverse effects. The LPN acknowledged the action was wrong and outside the CNA's scope of practice, and the CNA also stated she understood it was wrong in retrospect. The DON confirmed that both the LPN's and CNA's actions were not within professional standards of practice.
Failure to Apply Ordered Palm Pillow for Contracture
Penalty
Summary
Facility staff failed to provide appropriate treatment and services to maintain or improve range of motion for Resident #6, who had a physician's order dated 12/11/25 for a left-hand palm pillow to be applied at 7:00 a.m. and removed at 7:00 p.m. for a contracture. During observation on 3/17/26 and 3/18/26, the resident was seen clinching the left fist with no palm pillow in place. During interview, an LPN stated she believed the palm pillow was for the resident's contracture and that CNAs applied it. The Executive Director and DON were informed of the findings, and no facility policy regarding palm pillows was provided.
Failure to Implement Fall Prevention Interventions After Resident Falls
Penalty
Summary
The facility failed to implement interventions to prevent accidents for one resident after a fall. The resident fell on 12/21/25 and did not sustain an injury, but review of the resident’s comprehensive care plan, initiated on 5/29/25, and the December 2025 nurse’s notes did not show that staff addressed or implemented an intervention to prevent future falls. The resident fell again on 1/1/26 and again did not sustain an injury. During an interview on 3/18/26, an LPN stated that an intervention should be implemented after a resident falls for the resident’s safety and well-being. The facility policy stated that nursing staff will evaluate falls by assessing causation and contributing factors and implementing appropriate interventions to prevent reoccurrence.
Respiratory Care Deficiencies
Penalty
Summary
Facility staff failed to provide respiratory care and services for two residents. For one resident, the staff did not administer oxygen at the provider-ordered rate. The resident was observed multiple times lying in bed with eyes closed while receiving oxygen through a nasal device from a concentrator set just below 2 L/min, although the provider order dated 2/25/26 specified oxygen at 3.5 L/min via nasal cannula. The resident’s comprehensive care plan dated 6/23/25 did not include evidence related to oxygen administration. An LPN stated that residents needing oxygen should have a provider order specifying the rate and that the bubble on the concentrator should touch the bottom of the line of the ordered rate. For another resident, staff failed to store oxygen tubing and the nasal cannula in a sanitary manner. The resident had an order dated 3/2/26 for oxygen at 2 L/min as needed, and was observed lying in bed with the oxygen tubing and nasal cannula hung over the oxygen concentrator and resting against the back of the concentrator with no covering. An LPN stated that oxygen tubing should not be left out and that she would change the tubing or place it in a bag. The facility policy on oxygen did not document information about storage of oxygen tubing.
Bed Rail Risks and Consent Not Reviewed
Penalty
Summary
The facility staff failed to implement bed rail requirements for one of 19 residents, Resident #26. The clinical record showed a physician’s order dated 6/2/25 for a grab bar (bed rail) on the right side of the bed to assist with reducing pain, transfers, and repositioning in bed. However, the record did not show that the resident or the resident representative was made aware of the risks and benefits of bed rail use. The resident was observed lying in bed with the grab bar on the right side of the bed in an upright position on 3/17/26 at 2:10 p.m. and again on 3/18/26 at 7:41 a.m. During an interview on 3/18/26 at 2:39 p.m., an LPN stated residents should be made aware of the risks and benefits of bed rails. The facility policy titled Side Rail Assessment stated that if a resident is appropriate for side rail use, the resident or resident representative is to be educated on the risks and consent obtained.
Improper Disinfection of Glucometer
Penalty
Summary
The facility failed to follow infection control practices during blood glucose monitoring for one resident who required glucometer checks. During observation of medication administration, an LPN removed the glucometer from the medication cart, checked the resident’s blood glucose, and then cleaned the glucometer with an alcohol swab after the procedure. During interviews, the LPN stated the glucometer was dedicated to that resident and was cleaned after every use with an alcohol swab and allowed to air dry. Another LPN stated she knew the glucometer was wiped down after each use but was not sure what was used. The DON stated the glucometer should be wiped with either Sani-wipes or Clorox wipes and air dried, and that alcohol should not be used. The facility’s manufacturer instructions identified validated disinfecting wipes for the meter, including Dispatch Hospital Cleaner Disinfectant Towels with Bleach, Clorox Healthcare Bleach Germicidal and Disinfectant Wipes, and Medline Micro-Kill Bleach Germicidal Bleach Wipes.
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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.
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Nursing homes near Charlottesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Laurels Of Charlottesville | 0.4 mi | ★★★★★ | 0 | 0 |
| Charlottesville Health & Rehabilitation Center | 1 mi | ★★★★★ | 7 | 0 |
| Monroe Health & Rehab Center | 1.1 mi | ★★★★★ | 20 | 0 |
| Colonnades Health Care Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Cedars Healthcare Center | 1.9 mi | ★★★★★ | 0 | 0 |
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