Charlottesville Health & Rehabilitation Center

F 0558

Reasonably accommodate the needs and preferences of each resident.

Level of Harm - Minimal harm or potential for actual harm

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. The DON verbalized not having a staff coordinator at the present time, but that typically there are four to five certified nurse assistants (CNA's) on unit one on both day/evening shift and evening/night shift. On 9/3/25 at 4:20 p.m. CNA #1 (aide that worked

the weekend in question) was interviewed. CNA #1 verbalized that the unit should have four CNA's each shift. CNA #1 said that during that weekend the aides had thirty residents each and showers were not completed. CNA #1 said the other aide and herself helped each other and were able to provide hygiene and a shortened bed bath to residents, was able to feed residents with the help of other nursing staff and keep all the residents safe. CNA #1 said when a situation like that occurs that the staff prioritize what needs to be done and things like showers are not considered. On 9/4/25 at 9:00 a.m. license practical nurse (LPN #4-unit manager) was interviewed. LPN #4 the goal is to staff four CNAs on each twelve-hour shift, which does not always occur. LPN #4 verbalized when the unit is that short on help, the CNAs will do what is important for the resident. The above finding was presented to the DON and administrator on 9/3/25. No other information was presented prior to the exit conference on 9/4/25

Residents Affected - Some

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Charlottesville Health & Rehabilitation Center

505 West Rio Road Charlottesville, VA 22901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

practitioner's progress notes were reviewed. On 8-11-25, the nurse practitioner documented that the resident's son expressed concerns and requested that psychotropic medications be discontinued. On 8-13-25, the nurse practitioner again documented the son's request to discontinue the antipsychotic medications due to the resident experiencing increased confusion, agitation, and anxiety over the weekend.

The nurse practitioner documented her intent to discontinue these medications; however, the medications were not discontinued.During the clinical record review, a progress note dated 8/9/25 by a nurse practitioner indicated that Resident R5 exhibited an altered level of consciousness. The resident's son reported that Resident R5 was experiencing confusion, and the nurse observed Resident R5 asking if his son was inside the mirror he was looking at. On this date, the son requested that three medications, Amitriptyline, Trazodone and Seroquel to be discontinued due to concerns that they cause delirium. The medications were held for three days, and then restarted after the three-day hold, and lab work was obtained. Labs that were obtained were within normal limits and no concerns.On 9-3-25, a facility documentation review was conducted. The policy titled, General Guidelines for Medication Administration, read in part, medications are to be administered only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications, and that medications must be administered in accordance with written orders of

the prescriber.On 9-4-25 at 10:00 a.m., an interview was conducted with the Therapy Director. He stated that Resident R5 participated well in therapy and received all three disciplines-speech therapy, occupational therapy, and physical therapy. He explained that the resident ambulated several times a day, used NuStep, and completed exercises. The Therapy Director stated that although the resident became fatigued, he participated well and completed his therapy sessions.On 9/4/24 at 11:00 AM, the Administrator, Regional Director of Clinical Services, and Director of Nursing were informed of the concerns described above. They were advised that discharge orders had not been followed, resulting in two antipsychotic medications being added to the admission paperwork that were not on the discharge medication list. They were also informed that the resident's son had requested on 8/9, 8/11, and 8/12 that the three antipsychotic medications (Amitriptyline, Trazodone and Seroquel) be discontinued due to causing delirium. Additionally, they were informed of two progress notes written by the nurse practitioner indicating that while there was intent to discontinue these medications as requested, the medications were not actually discontinued. A request for

a policy for antipsychotic medication use was requested. The regional director of clinical services stated there was no policy related to psychotropic medications. On 9/4/25, a review of facility documentation was conducted. The policy titled, Physician Visits, read in part, that a discharging physician will provide patient information and orders to the facility at the time of admission. The patient's admission information is to be reviewed, and orders approved by the attending physician. The physician, nurse practitioner, or physician assistant is to review the patient's medical plan of care at each visit and provide documentation for the medical record'.No additional information was provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Charlottesville Health & Rehabilitation Center

505 West Rio Road Charlottesville, VA 22901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

of discharge there should be evidence that home health was set up. OS #5 said she could not recall all the details and was not sure what home health agency was contacted and was not sure about working the week Resident R6 was discharged . On 9/3/25 at 4:50 p.m. AS #3 verbalized after calling home health agencies in

the area where Resident R6 resided, AS #3 was able to evidence that Resident R6 started receiving home health care on 3/27/25 after being seen by Resident R6's primary care physician and making the referral and not the facility. On 9/3/25 at 5:30 p.m. the above finding was presented to the administrator, director of nursing and nurse consultant.The facilities Discharge Instruction policy read in part Discharge planning will be initiated and coordinated by the social service department who will assist the patient/family to make arrangements for transportation, care equipment, Home Health Services, etc. (the social service department and/or therapy will take responsibility for completion of arrangements).No other information was provided prior to the exit conference on 9/4/25.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Charlottesville Health & Rehabilitation Center

505 West Rio Road Charlottesville, VA 22901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

there were wrong entries for the medications and diagnosis. She stated her intent was to discontinue the three medications the son requested.On 9/4/25, a review of facility documentation was conducted. The policy titled, Physician Visits, read in part, that a discharging physician will provide patient information and orders to the facility at the time of admission. The patient's admission information is to be reviewed, and orders approved by the attending physician. The physician, nurse practitioner, or physician assistant is to

review the patient's medical plan of care at each visit and provide documentation for the medical record'.No additional information was provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Charlottesville Health & Rehabilitation Center

505 West Rio Road Charlottesville, VA 22901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Based on staff interview, clinical record review, and facility documentation review the facility staff failed to ensure medication review was performed by physician services on admission for one resident, Resident #5 (Resident R5) out of a survey sample of six residents. The findings included: On 9/3/25, a clinical record review of Resident #5 was conducted. The review showed the residents did not have a diagnosis of depression or delirium on the diagnosis list; however, amitriptyline was documented for depression without a corresponding diagnosis. A nurse practitioner's progress notes dated 8/11/25 and 8/13/25 documented the son's request for the antipsychotic medications (amitriptyline, trazodone and Seroquel) to be discontinued.

The nurse practitioner stated it was her intent to discontinue the medications, but she did not complete the discontinuation. The medications were ordered on admission, 8/4/25 and continued until Resident R5 was discharged on 8/15/25.On 9/4/25 at 9:00 a.m., an interview was conducted with the Minimum Data Set (MDS) Coordinator, LPN#1 (LPN1). LPN1 stated she reviewed Resident #5's diagnoses and was unable to find depression, or delirium. She stated the facility's nurse practitioner had assigned the diagnosis of depression, although there was no history of depression in the resident's hospital record. LPN1 further stated that delirium was noted in the nurse practitioner's progress notes, but the hospital discharge summary showed it had resolved; therefore, it was not placed on the diagnosis list. The MDS Regional Director, who participated by phone, stated the medication Amitriptyline was listed on the hospital record, but no diagnosis was documented with it.On 9/5/25 at 9:40 a.m., an interview was conducted with the nurse practitioner. The nurse practitioner stated the diagnosis of depression came from the hospital. She reported that when reviewing the history and physical and the hospital paperwork, she was unable to find the diagnosis of depression, but believed that was how she obtained it. When asked about the diagnosis of depression being linked to the antidepressant medication, she stated the nursing staff entered that diagnosis with the medication on admission, and she did not catch that the resident had no history of depression when she signed off on the paperwork.On 9/4/25, a review of facility documentation was conducted. The policy titled, Physician Visits, read in part, that a discharging physician will provide patient information and orders to the facility at the time of admission. The patient's admission information is to be reviewed, and orders approved by the attending physician. The physician, nurse practitioner, or physician assistant is to review the patient's medical plan of care at each visit and provide documentation for the medical record'.On 9/4/25 at 11:00 a.m., the administrator, director of nursing and the regional clinical care coordinator was made aware of the above concerns.No additional information was provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Charlottesville Health & Rehabilitation Center

505 West Rio Road Charlottesville, VA 22901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

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. The DON verbalized not having a staff coordinator at the present time and was currently taking on that role, but typically there are four to five certified nurse assistants (CNA's) on unit one on both day/evening shift and evening/night shift (7:00 a.m. to 7:00 p.m. and 7:00p.m. to 7:00 a.m.). Review of current as worked schedules indicated no staffing concerns. On 9/3/25 at 4:20 p.m. CNA #1 (an aide that worked the weekend in question) was interviewed.

CNA #1 verbalized that unit one should have four CNA's each shift. CNA #1 said during that weekend the aides had thirty residents each and showers were not completed. CNA #1 said the other aide and herself helped each other and were able to provide hygiene and a shortened bed bath to residents, was able to feed residents with the help of other nursing staff and keep all the residents safe. CNA #1 said when this occurred, the staff prioritized what needed to be done and showers are not considered. CNA #1 verbalized there were no incidents (such as falls or needs not being met) during this time period. CNA #1 verbalized

this was an isolated incident and has been better since agency has been allowed to come into the facility.

The above finding was presented to the DON and administrator on 9/3/25. The administrator verbalized that

the facility has had a lot of turnovers in employment and call outs especially on weekends. The administrator said that recently the facility has started using agency staff to fill in vacancies when needed and is working towards hiring more staff.On 9/4/25 at 9:00 a.m. license practical nurse (LPN #4-unit manager) was interviewed. LPN #4 the goal is to staff four CNAs on each twelve-hour shift, which does not always occur. LPN #4 verbalized when the unit is that short on help, the CNAs will do what is important for

the residents. On 9/4/25 the administrator presented the facility assessment and verbalized. Based on our census, acuity, and budget, the facility should be between four and five nursing assistants per shift.Review of incident logs, grievance logs, and resident council minutes did not evidence concerns regarding needs of residents or incident/accident concerns related to low staffing.The survey team conducted interviews regarding getting showers as scheduled with four residents in the survey sample, identified as Resident R1, Resident R2, Resident R3, and Resident R4. There were no concerns expressed except for Resident R1(resident council president) who wanted to change shower schedule to be done early in the morning prior to breakfast, because of handing out daily menus to residents just after breakfast. This information was presented to LPN #4, LPN #4 verbalized being aware of the preference and had just gone into effect. No other information was presented prior to the exit conference.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Charlottesville Health & Rehabilitation Center

505 West Rio Road Charlottesville, VA 22901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Review of Resident R6's clinical record documented (via a skin assessment dated [DATE REDACTED]) indicated that Resident R6 had a stage three pressure ulcer upon admission. The clinical record documented treatments were put in place and a wound care company began to monitor and treat the wound.

Further review of the daily skilled assessment progress notes dated 1/31/25 through 2/3/25 and weekly skin assessments dated 2/7/25 and 2/14/25 had inconsistent documentation of Resident R6 having a pressure ulcer either by documenting No on the progress notes or no documentation regarding a stage three pressure ulcer on skin assessments.

On 9/3/25 at 8:30 a.m. the director of nursing (DON) and nurse consultant (administrative staff, AS #3) were interviewed. AS #3 reviewed Resident R6's clinical record and agreed there were discrepancies in the skin assessments and progress notes.

A facility policy titled Wounds/Skin Impairments read in part, The Skin and Observation Tool will be completed by a licensed nurse [.], detailing any wounds/skin impairments.

No other information was provided prior to the exit conference on 9/4/25.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet