Cycle 1
Health 2023-03-09 · Fire 2023-03-09
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Charlottesville, VA
Westminster Canterbury Blue Ri
5-star overall rating with 4-star inspections with 8 recent health deficiencies
250 Pantops Mountain Rd, Charlottesville, VA
(434) 972-3100
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
27
Certified beds
Average residents
46
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-11-21
CMS approved date
Coverage
Medicare + 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
1.38
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
3.40
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
5.52
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
2.12
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
5.01
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
1.11
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.31
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.40
CMS adjusted RN staffing hours
Adjusted total hours
5.59
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
19%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
144
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
81.61
Composite VBP score used to determine payment impact.
Payment multiplier
1.0262
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 18.10% · Performance 16.21% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
7.13
Baseline 6.19% · Performance 5.70% · Measure score 7.13 · Achievement 7.13 · Improvement 3.57
Total nurse turnover
6.10
Baseline 34.21% · Performance 38.75% · Measure score 6.10 · Achievement 6.10 · Improvement 0
Adjusted total nurse staffing
9.41
Performance 5.76 hours · Measure score 9.41 · Achievement 9.41 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.79% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 141 · Observed rate 3.55% · Lower 95% interval 5.52% |
| Discharge to community | 73.69% |
50.57%
23.1 pts better
|
Better than the National Rate · Eligible stays 141 · Observed rate 81.56% · Lower 95% interval 68.42% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.84% |
95.27%
3.6 pts better
|
Numerator 85 · Denominator 86 |
| Falls with major injury | 1.16% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 86 |
| Discharge self-care score | 85.14% |
53.69%
31.5 pts better
|
Numerator 63 · Denominator 74 |
| Discharge mobility score | 85.14% |
50.94%
34.2 pts better
|
Numerator 63 · Denominator 74 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 86 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.7% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 90 · Observed rate 1.11% · Lower 95% interval 3.13% |
| Staff COVID-19 vaccination coverage | 11.75% |
8.2%
3.6 pts better
|
Numerator 37 · Denominator 315 |
| Staff flu vaccination coverage | 69.15% |
42%
27.2 pts better
|
Numerator 269 · Denominator 389 |
| Discharge function score | 83.78% |
56.45%
27.3 pts better
|
Numerator 62 · Denominator 74 |
| Transfer of health information to provider | 98.04% |
95.95%
2.1 pts better
|
Numerator 50 · Denominator 51 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 23 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 86.27% |
25.2%
61.1 pts better
|
Numerator 44 · Denominator 51 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.4
0.4 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.0%
6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.4% |
3.6%
3.8 pts worse
|
3.3%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 3.6% · Q3 6.9% · Q4 6.1% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
15.7%
15.7 pts better
|
11.4%
11.4 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 who lose too much weight | 10.7% |
5.7%
5 pts worse
|
5.4%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.4% |
20.2%
5.2 pts worse
|
19.6%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.1% |
15.0%
5.9 pts better
|
16.7%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 14.3% · Q3 9.1% · Q4 4.3% · 4Q avg 9.1% · 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 | 21.8% |
17.5%
4.3 pts worse
|
16.3%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.3% |
15.7%
5.4 pts better
|
14.9%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.5%
0.5 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.6%
0.1 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.3% |
22.2%
5.9 pts better
|
19.8%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 4.7% · Q3 8.7% · Q4 17.4% · 4Q avg 16.3% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
5.2%
1.2 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 6.9% · Q3 0.0% · Q4 5.2% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
74.6%
24.4 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.8% · Q4 97.4% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
11.7%
4.2 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 6.3% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.2%
0.7 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
73.6%
26.4 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.4% |
22.0%
5.6 pts better
|
23.9%
7.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.4% · Observed 10.8% · Expected 15.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-06-03 · Fire 2021-06-03
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-07-18 · Fire 2019-07-18
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2019-07-18
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-09-24
F · Potential for more than minimal harm
2019-07-18
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2019-09-24
F · Potential for more than minimal harm
2019-07-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-09-24
F · Potential for more than minimal harm
2019-07-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-09-24
F · Potential for more than minimal harm
2019-07-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-09-24
F · Potential for more than minimal harm
2019-07-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-09-24
Inspection history
Recent health citations
E · Potential for more than minimal harm
2023-03-09
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-03-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-03-09
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 2023-04-18
D · Potential for more than minimal harm
2023-03-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-03-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-03-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-03-09
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 2023-04-18
D · Potential for more than minimal harm
2023-03-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-18
D · Potential for more than minimal harm
2021-06-03
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 2021-07-09
F · Potential for more than minimal harm
2019-07-18
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2019-08-20
E · Potential for more than minimal harm
2019-07-18
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2019-08-20
E · Potential for more than minimal harm
2019-07-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-08-20
E · Potential for more than minimal harm
2019-07-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-08-20
D · Potential for more than minimal harm
2019-07-18
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 2019-08-20
D · Potential for more than minimal harm
2019-07-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-08-20
D · Potential for more than minimal harm
2019-07-18
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 2019-08-20
Penalties and ownership
What sits behind the stars
Ownership
Buchanan, Anna
Operational/Managerial Control · Individual
Selmeczi, Gary
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Albemarle Health & Rehabilitation Center
Charlottesville, VA
2-star overall rating with 1-star inspections with $63,294 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Colonnades Health Care Center
Charlottesville, VA
2-star overall rating with 1-star inspections with abuse icon flag with 22 recent health deficiencies
#3
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
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