Cycle 1
Health 2023-01-12 · Fire 2023-01-12
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Charlottesville, VA
Our Lady Of Peace Inc
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
751 Hillsdale Drive, Charlottesville, VA
(434) 973-1155
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
30
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-11-24
CMS approved date
Coverage
Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.97
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.61
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
4.28
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.66
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.87
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.14
CMS adjusted RN staffing hours
Adjusted total hours
4.98
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 48% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data. |
| Medicare spending per beneficiary | Not Available |
1.02
|
This provider is not required to submit SNF QRP data. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · This provider is not required to submit SNF QRP data. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.3 |
1.5
1.2 pts better
|
1.9
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.1 · Expected 0.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.4
0.3 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.6 · Expected 0.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
91.2%
4.5 pts better
|
93.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.1% · Q2 96.3% · Q3 96.7% · Q4 96.7% · 4Q avg 95.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
94.0%
2.7 pts better
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.6%
1.9 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.0% |
15.7%
9.7 pts better
|
11.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 7.4% · Q3 10.0% · Q4 3.3% · 4Q avg 6.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.7%
5.7 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 36.4% |
20.2%
16.2 pts worse
|
19.6%
16.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 36.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 33.9% |
15.0%
18.9 pts worse
|
16.7%
17.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 33.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.5% |
17.5%
2 pts better
|
16.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.0% |
15.7%
2.3 pts worse
|
14.9%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.5%
0.3 pts worse
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.3% |
1.6%
2.7 pts worse
|
1.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 10.0% · Q4 3.3% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.7% |
22.2%
11.5 pts better
|
19.8%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.6% · Q2 10.7% · Q3 6.1% · Q4 9.7% · 4Q avg 10.7% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
5.2%
2.1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 56.5% |
74.6%
18.1 pts worse
|
81.7%
25.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 56.5% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-03-25 · Fire 2021-03-25
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-07-11 · Fire 2019-07-11
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-01-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-02
F · Potential for more than minimal harm
2019-07-11
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-09-12
F · Potential for more than minimal harm
2019-07-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-09-12
F · Potential for more than minimal harm
2019-07-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-09-12
F · Potential for more than minimal harm
2019-07-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-09-12
Inspection history
Recent health citations
G · Actual harm
2023-01-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-07
G · Actual harm
2023-01-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-07
E · Potential for more than minimal harm
2023-01-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-03-07
D · Potential for more than minimal harm
2023-01-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-03-07
D · Potential for more than minimal harm
2023-01-12
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-03-07
D · Potential for more than minimal harm
2023-01-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-07
E · Potential for more than minimal harm
2021-03-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-04-30
E · Potential for more than minimal harm
2021-03-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-04-30
D · Potential for more than minimal harm
2021-03-25
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-04-30
D · Potential for more than minimal harm
2021-03-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-04-30
D · Potential for more than minimal harm
2021-03-25
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2021-04-30
E · Potential for more than minimal harm
2019-07-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-08-15
E · Potential for more than minimal harm
2019-07-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-07-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-07-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-07-11
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-07-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-07-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-07-11
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2019-08-15
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
The Laurels Of Charlottesville
Charlottesville, VA
2-star overall rating with 2-star inspections with $8,824 in total fines with 25 recent health deficiencies
#2
Charlottesville Health & Rehabilitation Center
Charlottesville, VA
3-star overall rating with 2-star inspections with 26 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Monroe Health & Rehab Center
Charlottesville, VA
4-star overall rating with 3-star inspections with $15,935 in total fines with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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