Charlottesville Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Charlottesville Health & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF686Aug 4, 2021

  Based on observation, staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to ensure that two of three residents in the survey sample did not develop avoidable pressure ulcers. Resident #2 developed an avoidable facility acquired Stage III pressure ulcer on her right buttock. Resident #3 developed five avoidable facility acquired unstageable pressure ulcers, one of which was not identified by the facility until eschar (dark scab) was present over the area. This was identified as harm. Findings were: During the entrance conference on 08/03/2021 at approximately 9:15 a.m., the DON (director of nursing) was asked for a list of all residents in the facility with facility acquired pressure ulcers. […]

• No harm, potential for more than minimal, patternF558Sep 4, 2025

  Based on staff interviews and facility document review, the facility failed to ensure resident preferences were met regarding showers for one of two units (unit one), which did not provide showers due to low weekend staffing. The findings include:Review of the facilities PBJ (Payroll Based Journal) indicated weekend staffing excessively low for the January through March 2025 quarter.Review of the as worked weekend scheduled for March 2025 revealed on March 8th and 9th (Saturday and Sunday) that there were two certified nursing assistants scheduled on unit one for 7 a.m. through 7 p.m. Review of the resident census log for these dates indicated a census of 59 residents on unit one.On 9/2/25 at 2:30 the director of nursing (DON) was interviewed regarding scheduling nursing staff. […]

• No harm, potential for more than minimal, patternF605Sep 4, 2025

  Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure that unnecessary psychotropic medications were not administered to one resident, Resident #5 (R5) out of a survey sample of six residents. The findings included:Staff completed the admission medication reconciliation using the resident's at-home medications rather than the physician-verified hospital discharge orders, resulting in the administration of two antipsychotic medications, Amitriptyline 10 mg at bedtime and Trazodone 100 mg at bedtime, that were not prescribed upon discharge. […]

• No harm, potential for more than minimal, patternF725Sep 4, 2025

  Based on staff interviews and facility document review, the facility failed to ensure sufficient staffing in accordance with the facility assessment on one of two units (unit one), which had excessively low weekend staff. The findings include: Review of the facilities PBJ (Payroll Based Journal) indicated weekend staffing excessively low for the January through March 2025 quarter. Review of the as worked weekend scheduled for March 2025 revealed on March 8th and 9th (Saturday and Sunday), there were two certified nursing assistants scheduled on unit one for 7 a.m. through 7 p.m. Review of the resident census log for these dates documented a census of 59 residents on unit one. On 9/2/25 at 2:30 the director of nursing (DON) was interviewed regarding scheduling adequate nursing staff. […]

• No harm, potential for more than minimal, patternF803Mar 19, 2025

  Based on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to follow the menu for both meals observed, affecting multiple residents, including Resident #2-R2, Resident #3 - R3, Resident #4 -R4, and Resident #5-R5, who resided on two of two nursing units. The findings included: 1. The facility staff failed to prepare and serve foods in accordance with the posted menu. On 3/18/25, the daily menu was observed to be posted on each of the nursing units and outside the main dining room. The menu indicated breakfast included: scrambled eggs, sausage patty, cranberry muffin, orange juice, hot coffee or tea, and assorted milk options. On 3/18/25, at approximately 8:00 a.m., observations were conducted on each of the units. […]