Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Westminster Canterbury Blue Ri during CMS and state inspections, most recent first.
Unsafe wheelchair transfer resulted in hip fracture. A resident with incomplete paraplegia and MS, who required a Hoyer lift with 2 staff for all transfers, was moved from bed to a tilt-and-space wheelchair when the chair backrest reportedly collapsed or unlocked and the resident slid/fell out of the chair. Staff accounts varied, but the resident was sent to the hospital and diagnosed with an acute closed right femoral neck fracture.
Failure to accurately assess and classify an open wound for a resident with stroke, L hemiplegia, impaired cognition, and significant ADL dependence. Nursing notes documented worsening sacral and buttock skin breakdown, including an unstageable sacral eschar and later progression of superficial skin damage to an unstageable area. The CCC stated she was the primary wound assessor, had no formal education in wound staging or root cause analysis, and believed the sacral wound was caused by pressure but complicated by moisture.
Governing Body oversight failed when a resident did not receive podiatry services and another resident did not receive treatment and services to prevent and heal pressure ulcers. The Administrator and DON stated they were unsure whether the QAPI committee discussed foot care and podiatry services, and the Administrator said issues with podiatry services and pressure ulcers had been identified but no action plan was put in place. The facility's QAPI policy states the HSA is responsible for overseeing the QAPI program.
The facility failed to use its QAPI process to address deficiencies in foot care and pressure ulcer care. A resident did not receive podiatry services, and another resident did not receive treatment and services to prevent and heal pressure ulcers. The Administrator stated the QAPI committee was not sure whether foot care and podiatry issues were discussed, and that although issues were identified for both areas, no action plan was put in place.
Failure to treat a resident with respect and dignity: A resident with dementia, diabetes, and severely impaired cognition was publicly told by a sitter and an LPN that he could not have dessert because his blood sugar was too high and because his wife was concerned about it. The resident was then assisted away from the table without dessert, and the care plan did not identify an intervention to withhold dessert for elevated blood sugar.
A resident with dementia and heart failure, who was dependent on staff-operated wheelchair use and needed extensive help with ADLs, was observed in the dining room with the entire left wheel of the wheelchair splattered with a dense white substance during lunch meal observations.
Physical restraint used for a resident with severe cognitive impairment. A resident with dementia and Parkinson's disease, who was oriented to person only and dependent in all ADLs, was observed seated in a reclined chair. The CCC stated the resident had a history of falls due to balance and gait problems, that the wife wanted falls prevented, and that the recliner was used because there was no personal sitter and not enough staff to maintain safety.
Failure to Timely Report Allegation of Verbal Abuse: A resident with intact cognition and ADL dependence reported that a CNA was loud, rude, bossy, and disrespectful during care, making her feel scared. The resident told another CNA she wanted to speak with the ADON about the verbal abuse, but the concern was not addressed right away and the ADON did not speak with the resident about the allegation until later.
Failure to provide needed podiatry and foot care: A resident with Foot Drop and PVD, who was dependent for several ADLs and cognitively intact, reported not getting toenails trimmed for months. Surveyors observed thick, yellow, long, curvy toenails on both feet, while records showed the resident was not on the podiatry list despite a prior podiatry note documenting elongated, deformed toenails and inability to care for her feet. Staff interviews indicated podiatry depended on nurse/CNA identification and documentation, and the QAPI noted missing documentation related to podiatry services and refusals.
Failure to Provide Incontinence Care: A resident with dementia, diabetes, recurrent UTIs, and mixed bladder incontinence was observed wearing urine-soaked pants during and after a meal. The personal sitter said she was not authorized to provide incontinence care and was waiting for the CNA, and she did not know how long it had been since the resident last received care. The care plan directed q2h checks and perineal care after incontinence episodes, but the resident remained in the same soiled clothing later that day.
A resident with dementia, diabetes, and severely impaired cognition was observed eating lunch, but after the resident stopped eating, a requested dessert was not served before the personal sitter assisted the resident away from the table. The RD stated the resident should have received the dessert or a compatible substitute because it was intended to meet nutritional needs for that meal. The care plan identified risk for unintentional weight loss and directed staff to provide the ordered diet and monitor intake.
Medication Error Rate Exceeded Allowed Threshold: An LPN failed to fully administer ordered MiraLax to three residents during med pass observations. One resident with severe cognitive impairment was left with the medication cup beside her, another with severe impairment had most of the liquid poured into a drain after partial sipping, and a third resident with moderate impairment was left before finishing the dose. The facility’s medication error rate was identified as 11.54%.
Homelike Environment Not Maintained: A resident with major depressive disorder and generalized muscle weakness was observed in his room with a medium-sized hole in the wall behind his recliner and peeling sheetrock on the adjacent wall. The resident said he had not known about the hole and that the peeling area had been there for a while, and a CNA stated she had always noticed the hole.
Unsafe wheelchair transfer resulted in resident hip fracture
Penalty
Summary
The facility failed to ensure a safe transfer from bed to wheelchair for one resident, who had incomplete paraplegia and relapsing remitting Multiple Sclerosis and was dependent for chair-to-bed transfers. The resident’s care plan directed use of a Hoyer lift with two staff for all transfers, and the resident was transferred to a wheelchair using that lift. During the transfer, the wheelchair backrest was involved in the event and the resident fell from the chair to the floor. Facility documentation and staff interviews described the incident in different ways, including that the wheelchair toppled, the back of the wheelchair collapsed, or the resident slid out of the chair after the backrest gave way. A CNA stated that after the resident was transferred into the wheelchair and the sling was removed, the back of the chair was raised so the resident could sit upright, and when the brakes were released and the back was set up, it suddenly unlocked and fell, sending the resident forward out of the chair. Another CNA stated the backrest broke down and caused the resident to slide to the floor. The resident was sent to the hospital and diagnosed with an acute closed right femoral neck fracture after the fall from the wheelchair transfer. The resident and family reported that the resident fell out of the wheelchair during the transfer and broke her hip. OT and PT examined the wheelchair after the incident but could not determine a malfunction, while the DOF demonstrated that the wheelchair could be safely positioned and stated no mechanical issues were found.
Failure to Accurately Assess and Classify an Open Wound
Penalty
Summary
Facility staff failed to accurately assess and classify an open wound for Resident #30, who was admitted with a stroke and left hemiplegia and whose MDS significant change assessment coded moderately impaired cognition for daily decision-making. The resident’s care plan identified substantial dependence for most activities of daily living, and a Braden Scale assessment on 4/3/26 scored 11, with directions to obtain treatment orders, place them on the TAR, notify the RD, obtain an air mattress, add a task for turning and repositioning every 2 hours, and notify the physician and family. Clinical notes documented worsening skin breakdown and wound treatment changes. On 3/31/26, nursing documented a new unstageable eschar on the midline sacrum measuring 4 x 1 cm and denuded areas on the right buttock, with the physician agreeing to continue Xeroform and Allevyn daily. On 4/14/26, nursing documented that superficial skin damage related to incontinence had progressed to an unstageable area over the right aspect of the lower sacrum. When the wounds were observed on 4/15/26, the right buttock wound appeared as two areas with epithelial tissue, while the sacral wound was smaller and had dry yellowish tissue in the wound bed. The CCC stated she was the primary wound assessor, had no formal education in assessing or staging wounds or determining root cause analysis, and believed the sacral wound was caused by pressure but complicated by moisture.
Governing Body Failed to Ensure QAPI Oversight for Foot Care and Pressure Ulcer Services
Penalty
Summary
The facility's Governing Body failed to ensure that facility policies were implemented for managing and operating the facility in a way that supported effective systems for resident quality of life in the areas of foot care and treatment/services to prevent and heal pressure ulcers. During the recertification survey completed on 4/15/26, surveyors found that the facility failed to provide podiatry services for Resident #11 and failed to provide treatment and services to prevent and heal pressure ulcers for Resident #30. During an interview on 4/15/26 at 4:12 PM, the Administrator and DON stated they were not sure whether the QAPI committee discussed foot care and podiatry services. The Administrator also stated that the facility identified issues regarding podiatry services but no action plan was put in place, and identified issues with pressure ulcers but no action plan was developed. The facility's QAPI policy, last revised 6/17/2022, states that the Health Services Administrator is responsible for overseeing the QAPI program. At a final interview later that evening, the Administrator, DON, Regional President of Operations, Admission Coordinator, Nurse Educator, Rehab Manager, and ADON were given an opportunity to provide additional information and had no further comments.
QAPI Committee Failed to Address Foot Care and Pressure Ulcer Deficiencies
Penalty
Summary
The facility failed to adequately identify, keep systems functioning properly, and implement necessary action plans through its QAPI committee to address deficiencies related to foot care and treatment/services to prevent and heal pressure ulcers. During the recertification survey completed on 4/15/26, the facility failed to provide podiatry services for Resident #11 and failed to provide treatment and services to prevent and heal pressure ulcers for Resident #30. During an interview on 4/15/26 at 4:12 PM, the Administrator stated she was not sure whether the QAPI committee discussed foot care and podiatry services. She also stated the facility identified issues regarding podiatry services but no action plan was put in place, and that issues regarding pressure ulcers were identified but no action plan was developed. The facility’s QAPI policy, last revised 6/17/2022, states the QAPI plan provides evidence that, through the Quality Assessment and Assurance committee, it has identified its own quality deficiencies and is making a good faith attempt to correct them.
Failure to Treat a Resident with Respect and Dignity
Penalty
Summary
The facility failed to treat 1 of 24 residents, Resident 20, with respect and dignity. Resident 20 was admitted with diagnoses including dementia and diabetes, and the admission MDS coded the resident as having severely impaired cognitive abilities for daily decision making, with a BIMS score of 3 out of 15. The resident also required varying levels of assistance with activities of daily living, including oral hygiene, eating, bathing, dressing, personal hygiene, and footwear. During lunch, Resident 20 was observed seated at the dining table eating. After the resident stopped eating and requested dessert, the personal sitter told the resident in a resonating voice that he could not have dessert because his sugar was too high. When the resident asked again, an LPN publicly stated that he could not have dessert because his wife was concerned about his elevated blood sugar, and added that sugar-free pudding could be provided if available. The personal sitter then assisted the resident away from the table without any dessert being served. The resident’s person-centered care plan did not identify an intervention to withhold dessert if blood sugar was elevated, and the CCC and RD later stated that the resident should have received a dessert.
Wheelchair Not Kept Clean
Penalty
Summary
The facility failed to ensure that resident care equipment was kept clean for Resident 31. The resident was admitted with diagnoses including dementia and heart failure, and the quarterly MDS coded the resident as unable to complete the BIMS, with long-term and short-term memory problems and severe impairment in daily decision making. The resident also required assistance with multiple ADLs and was dependent on a wheelchair operated by staff. During observations in the dining room at the lunch meal on 4/13/26 and 4/14/26, the entire left wheel of the resident’s wheelchair was observed to be splattered with a dense white substance.
Physical restraint used for resident with severe cognitive impairment
Penalty
Summary
The facility failed to ensure that Resident 49 was free from the use of a physical restraint unless needed for medical treatment. Resident 49 was admitted with diagnoses including dementia and Parkinson's disease. The admission functional assessment showed the resident was oriented to person only, had severely impaired cognition, and was dependent in all activities of daily living. The resident had not been in the facility long enough for an MDS to be completed, so the admission assessment was used for review. On observation, Resident 49 was seen seated in a reclined chair in the living room area. During interview, the Clinical Care Coordinator stated the resident had a history of falls related to balance and gait problems, including loss of upper-body balance, and that the resident's wife was adamant that falls be prevented. The CCC stated the recliner chair was necessary because the resident did not have a personal sitter and there was not enough staff to maintain his safety. The CCC also stated the resident had urinary problems related to kidney problems, a history of UTIs, and required bladder scans four times each day. During the final interview, facility leadership was given the opportunity to provide additional information and had no further comments.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
Facility staff failed to timely report an allegation of verbal abuse involving Resident #11 to the appropriate state agencies. Resident #11 was admitted to the facility after an acute care hospital stay and later re-admitted from an acute care facility. The resident’s annual MDS assessment coded a BIMS score of 13 out of 15, indicating intact cognitive abilities for daily decision making. The care plan identified ADL self-care performance deficits related to activity intolerance, disease process, fatigue, and musculoskeletal impairment, with the resident dependent for oral hygiene, toileting hygiene, and showering/bathing, and requiring set-up or clean-up assistance with eating. The facility synopsis documented that the resident reported being afraid of CNA #6 after the CNA was loud, rude, snippy, and disrespectful during care. During the initial tour, Resident #11 stated that CNA #6 was loud, bossy, and boisterous, and that the CNA’s words, body language, and rudeness made her feel scared. The resident said she asked CNA #5 to get the ADON so she could report the incident, but the ADON did not come to speak with her at that time. CNA #5 stated the resident told her around 10:00 a.m. that CNA #6 had been rude and abrupt and that the resident was afraid to report it. The timeline showed the resident was verbally abused on 4/13/26, informed CNA #5 the next morning, and the ADON did not speak with the resident about the allegation until 4/15/26.
Failure to Provide Needed Podiatry and Foot Care
Penalty
Summary
The facility failed to ensure that Resident #11 received necessary foot care and podiatry services to maintain good foot health. Resident #11 was admitted with diagnoses including Foot Drop and Peripheral Vascular Disease, had intact cognition with a BIMS score of 13, and was dependent for several ADLs. The care plan directed staff to check nail length and trim and clean nails on bath day and as necessary, but the resident told surveyors she had been asking the nurse for 3 months about not getting her toenails trimmed. During observation, the resident’s toenails on both feet were noted to be thick, yellowish, long, and curvy, and the nurse said she would enter a note and add the resident to the podiatry list. Record review showed the resident was not listed as receiving podiatry services, and the most recent podiatry note documented elongated, deformed toenails x10, inability to care for her feet, and a request for toenail trimming, with a plan for clinic visit and reduction of deformed toenails. Interviews with the MRC and LPN indicated staff relied on nurse or CNA identification of need and that the podiatrist visited every other Thursday. The ADON stated the resident had no history of refusals and that an appointment had been set for the next day. The facility’s QAPI identified a lack of documentation regarding podiatry services provided to healthcare residents and noted there was no documentation supporting a refusal of services.
Failure to Provide Incontinence Care
Penalty
Summary
Facility staff failed to provide necessary incontinence care for Resident 20, who was admitted with diagnoses including dementia, diabetes, and a history of recurrent urinary tract infections secondary to hydronephrosis related to obstruction. The admission MDS coded the resident as severely cognitively impaired, with a BIMS score of 3 out of 15, and the care plan identified mixed bladder incontinence related to confusion, a history of UTIs, and impaired mobility. The care plan directed staff to check the resident every 2 hours and, as needed for incontinence, wash, rinse, and dry the perineum and change clothing after incontinence episodes. During observation, Resident 20 was seen leaving the dining table with assistance from a personal sitter while wearing urine-soaked pants along the brief line on the left side. Later the same day, the resident was observed seated in a chair in his room wearing the same pants. The personal sitter stated she was not authorized to provide incontinence care and was waiting for the CNA to become available, and she did not know how long it had been since the resident last received incontinence care. The CCC stated the resident had a history of urinary problems because of kidney problems and UTIs and that the facility scanned his bladder four times each day.
Failure to Serve Ordered Dessert/Compatible Substitute
Penalty
Summary
Provide enough food and fluids to maintain a resident’s health was not met for Resident 20. The resident was admitted with diagnoses including dementia and diabetes, and the admission MDS dated 2/11/26 coded a BIMS score of 3 out of 15, indicating severely impaired cognitive abilities for daily decision making. In section GG0130, the resident was coded as needing setup or clean-up assistance with oral hygiene, supervision or touching assistance with eating, substantial/maximal assistance with showering/bathing and upper body dressing, and dependent assistance with lower body dressing, personal hygiene, and putting on/taking off footwear. On 4/13/26 at about 12:50 PM, Resident 20 was observed seated at the dining table eating lunch. Shortly after the resident stopped eating, dessert was requested, but the personal sitter assisted the resident in leaving the table without a dessert being served. When this was discussed with facility staff on 4/14/26, the RD stated the resident should have received the dessert or a compatible substitute because the order was intended to meet nutritional needs for that meal. The care plan identified a problem dated 2/8/26 related to potential unintentional weight loss due to increased ADL needs, Alzheimer’s disease with variable appetite, and acute UTI, with a goal to maintain adequate nutritional status and interventions to provide the ordered diet, monitor intake, and record each meal.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5 percent; the rate was identified as 11.54%. During observation of medication administration on 4/14/26, LPN #2 did not complete administration of MiraLax for three residents. The report states that the medication was prepared and handed to the residents, but the LPN did not remain with them until the medication was fully consumed or otherwise administered as ordered. Resident #32 had diagnoses including atrial fibrillation and anemia, and the MDS coded a BIMS score of 7 out of 15, indicating severe impairment in daily decision-making. The physician order was for MiraLax 17 grams by mouth once daily for constipation, mixed in at least 4 ounces of liquid. At 10:06 AM, the LPN prepared the medication, handed the cup to the resident, and left. Later that morning, the resident was observed with the cup of medication beside her, and it had not been consumed. The LPN later stated she failed to administer MiraLax completely. Resident #10 had Alzheimer's disease and a BIMS score of 3 out of 15, indicating severe impairment. The same MiraLax order was in place, and at 10:31 AM the LPN prepared the medication, handed the cup to the resident, and assisted her in sipping the liquid. The resident slowly sipped with great prompting, but the LPN then stopped assisting and poured approximately 65% of the liquid into the water fountain drain. Resident #14 had Alzheimer's disease and a BIMS score of 8 out of 15, indicating moderate impairment. For this resident, the LPN prepared the MiraLax, handed the cup to the resident, explained it was MiraLax, and left the room before the resident finished it. The LPN later stated she failed to administer MiraLax completely.
Homelike Environment Not Maintained
Penalty
Summary
The facility failed to provide a homelike environment for one resident in the survey sample. Resident #4, who was originally admitted after an acute care hospital stay and later readmitted, had diagnoses including major depressive disorder and generalized muscle weakness. The annual MDS assessment coded the resident as completing the BIMS with a score of 14 out of 15, indicating intact cognitive abilities for daily decision making. During the initial tour of room [ROOM NUMBER]-1, the resident was observed sitting in a recliner while the wall behind the recliner had a medium-sized hole and the wall to the right of the recliner had a peeling outer layer of sheetrock. The resident stated he had never known about the hole and said the peeling area had been there for a while. A CNA stated she had worked at the facility for 1 year and had always noticed the hole in the wall.
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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) |
|---|---|---|---|---|
| Albemarle Health & Rehabilitation Center | 2.4 mi | ★★★★★ | 10 | 1 |
| Colonnades Health Care Center | 3.5 mi | ★★★★★ | 0 | 0 |
| The Laurels Of Charlottesville | 3.6 mi | ★★★★★ | 0 | 0 |
| Our Lady Of Peace Inc | 3.7 mi | ★★★★★ | 15 | 0 |
| Cedars Healthcare Center | 3.9 mi | ★★★★★ | 0 | 0 |
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