Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Laurels Of Charlottesville during CMS and state inspections, most recent first.
Facility staff did not post the grievance procedure or identify the grievance officer in any nursing units or the lobby, and neither residents nor staff knew how to file a grievance or who the grievance officer was. A grievance filed by a resident's responsible person was not resolved within the facility's required timeframe, instead being addressed only at the time of the resident's discharge.
Multiple residents did not receive care as ordered, including missed or incorrect medication doses, failure to monitor and document vital signs and weights as prescribed, and lack of timely physician notification regarding significant changes. These deficiencies were identified through interviews, record reviews, and direct observation, with staff acknowledging the lapses and no further information provided by facility leadership.
Facility staff failed to accurately complete the MDS for a resident with multiple diagnoses, including a sacral pressure ulcer that was present and being treated upon admission. The MDS did not reflect the presence of the pressure ulcer, despite clinical documentation and ongoing wound care, due to an oversight by the RN MDS coordinator.
Staff failed to administer medications within the required timeframe for a resident with diabetes, repeatedly giving insulin and other medications outside the one-hour window of scheduled times. In a separate incident, an LPN left medications with a resident and walked away without confirming ingestion, which was later discovered by the resident’s family. Additionally, staff did not document a thorough assessment of a pressure ulcer for another resident, omitting details such as size and appearance until a week after admission. These actions did not meet professional standards of nursing practice.
Facility staff did not provide required ADL assistance to three residents, including failure to assist with shaving, inadequate meal setup and feeding support for a resident with upper extremity impairments, and lack of timely response to call bells resulting in two residents remaining in wheelchairs for hours and one calling 911 for help. Documentation and staff interviews confirmed these lapses in care.
A resident with multiple chronic conditions had physician orders for daily wound care, but nursing staff failed to document wound care or the resident's refusals on the TAR for two shifts. Interviews confirmed that the resident refused treatment, but the assigned nurses did not record the refusals as required, resulting in incomplete medical records.
Two certified nursing assistants did not receive the required training for caring for residents with cognitive impairments, as confirmed by staff interviews and a review of training records. The staff development coordinator was responsible for ensuring training, but documentation showed that not all staff completed the necessary dementia care education.
A facility staff member failed to follow physician's orders for tube feeding flushes for a resident. The LPN did not perform the required water flushes before and between medications, nor before the bolus feeding, as observed during a survey. The LPN admitted to misreading the orders, and the deficiency was confirmed through clinical record review and facility policy. The issue was discussed with the facility's administration and clinical staff, resulting in a deficiency citation, F693.
Failure to Post Grievance Procedure and Timely Resolve Resident Grievance
Penalty
Summary
Facility staff failed to resolve a resident grievance in a timely manner, did not post the identification of the grievance officer, and did not display the grievance procedure in the facility. During a tour of multiple nursing units and the lobby, surveyors observed that there was no information posted regarding the grievance officer or the process for filing a grievance. At a resident council meeting attended by 15 residents, none were aware of who the grievance officer was or how to file a grievance. Residents expressed that they were unaware of grievance forms and did not know if a grievance officer existed at the facility. Interviews with staff, including the activity director and social service director, revealed that they also did not know who the grievance officer was. The administrator later stated that they were currently acting as the grievance officer due to staff turnover, and confirmed that there was no posting about the grievance officer or procedure. A review of facility documentation showed that a grievance filed by a resident's responsible person listed five concerns and was not resolved until the resident's discharge, which was nearly three weeks after the grievance was filed. The facility's policy requires that concerns be discussed with the interdisciplinary team the day after receipt and that investigations be completed within 5-7 business days. The delay in resolving the grievance and the lack of posted information about the grievance process and officer were confirmed during the survey, and no additional information was provided by facility leadership prior to the exit interview.
Failure to Follow Physician Orders and Medication Administration Protocols
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders, resident preferences, and goals for seven residents. In one case, a resident with multiple diagnoses including cellulitis, amputation, and MRSA did not receive a scheduled dose of Cefazolin antibiotic because the medication was not administered as ordered, despite the medication being available in the STAT box. The nurse on duty did not utilize the available medication, and there was no documentation explaining the omission. Another resident was administered an incorrect dose of Baclofen, receiving 10 mg in the morning instead of the ordered 5 mg. The LPN responsible for the medication pass took the dose from the supply card labeled for bedtime, rather than the correct morning dose, even though the correct medication was available. Additionally, a resident with orders for vital signs every shift did not have these assessments completed on two separate day shifts, with no explanation documented in the clinical record. Further deficiencies included failure to administer insulin as ordered and within the standard time frame, with missed or delayed doses and lack of documentation or physician notification regarding omissions. Several residents with orders for daily weights and physician notification for significant weight changes did not have weights recorded on multiple days, and in some cases, significant weight changes were not communicated to the physician as required. These failures were confirmed through interviews, clinical record reviews, and facility documentation, with no additional information provided by the facility prior to the survey's conclusion.
Inaccurate MDS Assessment for Pressure Ulcer
Penalty
Summary
Facility staff failed to complete an accurate Minimum Data Set (MDS) assessment for one resident who was admitted with multiple diagnoses, including cerebrovascular accident, hemiplegia, atrial fibrillation, aphasia, cognitive communication deficit, diabetes, dysphagia with gastrostomy, dementia, hypertension, and a pressure ulcer. The resident's clinical record documented the presence of a stage 2 sacral pressure ulcer upon admission, with corresponding physician orders and daily wound care treatments recorded in the treatment administration records. Despite this documentation, the admission MDS completed for the resident did not indicate the presence of any unhealed pressure ulcers or injuries in Section M0210, omitting the sacral pressure ulcer that was present and being treated. During an interview, the RN MDS coordinator acknowledged that the pressure ulcer should have been coded on the MDS as present upon admission and attributed the omission to an oversight. The deficiency was confirmed through staff interview and clinical record review, and was discussed with facility leadership during the survey.
Failure to Follow Professional Standards in Medication Administration and Wound Assessment
Penalty
Summary
Facility staff failed to adhere to professional standards of nursing practice in several instances involving three residents. For one resident with multiple insulin orders, staff did not administer insulin and other medications within the required one-hour window of the scheduled time on numerous occasions. This included delays of up to several hours for both scheduled and sliding scale insulin doses, as well as a weekly injectable medication. The resident expressed concern about the timing of her insulin administration, noting that doses were sometimes given so late that subsequent doses had to be skipped or were administered too close together. The Director of Nursing confirmed that medications are expected to be given within an hour of the scheduled time, and facility documentation corroborated the repeated delays. In another case, a nurse provided a resident with medication and left the room without ensuring the medication was ingested. The incident was discovered when the resident’s family found medications left on the bed. The nurse involved acknowledged walking away while the resident was taking the medication and was subsequently reprimanded. There was no documentation in the clinical record or progress notes regarding this incident, and the unit manager confirmed the event had occurred and that staff are not permitted to leave medications with residents unsupervised. For a third resident, staff failed to document a thorough assessment of a pressure ulcer upon admission and during the first week of the resident’s stay. The initial nursing assessment noted the presence of a stage 2 pressure ulcer but did not include any description of the wound’s size, appearance, or characteristics. Daily treatment was provided and documented, but no descriptive assessments were recorded until a week later when a wound nurse practitioner performed a detailed evaluation. Both the unit manager and the DON acknowledged that nurses are expected to document wound appearance and characteristics, and facility policy requires such documentation for residents with wounds.
Failure to Provide ADL Assistance to Dependent Residents
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living (ADLs) for three residents who required varying levels of support. One resident, who required moderate to maximum assistance with all self-care, was not shaved by staff during his stay, despite repeated requests from his spouse. Documentation and interviews confirmed that staff were hesitant to shave him, and the issue was only addressed on the day of discharge, after a grievance was filed. Another resident, who had significant upper extremity impairments and required setup or clean-up assistance for eating, did not receive the necessary support during a meal. The resident was found upset, unable to access or eat her breakfast due to missing utensils, unopened food items, and the absence of milk for her cereal. The dietary manager confirmed the deficiencies in meal setup and food quality, and the resident's clinical record supported her need for assistance. A third resident, who required extensive two-person assistance for bed mobility, transfers, and toileting, reported not receiving care for over two and a half hours despite repeated use of the call bell. The resident and her roommate remained in their wheelchairs all day, resulting in pain and distress, and the resident's son ultimately called 911 for help. Documentation for the relevant shift was blank, and staff interviews confirmed that lack of documentation indicated care was not provided. No grievance was filed for this incident, and facility leadership was unaware of the event until informed by surveyors.
Failure to Document Wound Care and Resident Refusals
Penalty
Summary
A deficiency was identified when the facility failed to ensure complete and accurate documentation of wound care for one resident. The resident, who had a history of cellulitis, right toe amputation, congestive heart failure, MRSA, and diabetes, was admitted with an order for daily and evening wound care and dressing changes to the right foot. Review of the Treatment Administration Record (TAR) revealed that documentation was missing for the day shift on 3/16/25 and the evening shift on 3/17/25, with no indication that the dressing changes were completed or refused. Interviews with nursing staff confirmed that the resident had refused the dressing changes on the dates in question. However, the assigned nurses did not document the refusals on the TAR or in a progress note, as required. One nurse acknowledged forgetting to document the refusal due to being busy, and it was noted that the resident often refused dressing changes. The lack of documentation was confirmed by the unit manager and discussed with facility leadership.
Failure to Provide Required Dementia Care Training to Staff
Penalty
Summary
Facility staff failed to ensure that all staff received the required training related to the care of residents with cognitive impairments, including dementia. During interviews and a review of facility documentation, it was determined that two out of five certified nursing assistants reviewed did not complete the necessary training for caring for cognitively impaired residents. The staff development coordinator was responsible for providing training and orientation, and the facility's annual training schedule was supposed to include dementia care. However, training records showed that two certified nursing assistants had not received this required training, as confirmed by the staff member overseeing training and the documentation reviewed.
Failure to Follow Physician's Orders for Tube Feeding Flushes
Penalty
Summary
The facility staff failed to adhere to physician's orders regarding tube feeding flushes for a resident, identified as Resident #1 (R1), during a survey. The deficiency was observed when an LPN administered medications and a bolus tube feeding to R1 without performing the required water flushes as per the physician's orders. Specifically, the LPN did not flush the peg tube with 15cc of water before and between medications, nor did they flush with 50cc of water prior to the bolus feeding, although a 120cc flush was administered after the bolus feeding. Upon interview, the LPN acknowledged the oversight, stating that they misread the orders. A review of R1's clinical records confirmed the physician's orders for specific water flushes before and after medication administration and bolus feedings. The facility's policy on medication administration via enteral routes also outlined the necessity of verifying medication orders and performing water flushes between medications. The deficiency was discussed with the facility's administration and clinical staff, and it was substantiated with a deficiency citation, F693.
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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) |
|---|---|---|---|---|
| Our Lady Of Peace Inc | 0.4 mi | — | 15 | 0 |
| Monroe Health & Rehab Center | 0.8 mi | — | 0 | 0 |
| Charlottesville Health & Rehabilitation Center | 1.1 mi | — | 0 | 0 |
| Colonnades Health Care Center | 1.1 mi | — | 0 | 0 |
| Cedars Healthcare Center | 1.5 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.