OUR LADY OF PEACE INC

CHARLOTTESVILLE, VA · 30 beds · Non profit - Church related

65 Trust Score
Grade: C MEDIUM Risk → Stable

Red Flags

  • No standard inspection in over 2 years
  • 2 citation(s) where residents suffered actual harm

Green Flags

  • 5-star staffing rating
  • Below-average deficiency count (6 vs 15 state avg)
  • No fines or penalties on record
  • Above-average RN staffing (1.14 hrs vs 0.67 state avg)

Quick Facts

★★★★☆
CMS Overall
★★★☆☆
Health Inspection
6
0.4x state avg
Deficiencies
$0
Fines (3-yr)
★★★★★
Staffing

Violation Timeline

January 11, 2023

6 deficiencyies
F0656 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

F0657 Potential Harm Scope/Severity: E

Resident Assessment and Care Planning Deficiencies

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Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

F0661 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

F0684 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide appropriate treatment and care according to orders, resident’s preferences and goals.

F0686 Actual Harm Scope/Severity: G

Quality of Life and Care Deficiencies

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Provide appropriate pressure ulcer care and prevent new ulcers from developing.

F0692 Actual Harm Scope/Severity: G

Quality of Life and Care Deficiencies

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Provide enough food/fluids to maintain a resident's health.

March 24, 2021

5 deficiencyies
F0655 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

F0656 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

Show details

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

F0684 Potential Harm Scope/Severity: E

Quality of Life and Care Deficiencies

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Provide appropriate treatment and care according to orders, resident’s preferences and goals.

F0758 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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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.

F0880 Potential Harm Scope/Severity: E

Infection Control Deficiencies

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Provide and implement an infection prevention and control program.

July 10, 2019

8 deficiencyies
F0656 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

Show details

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

F0657 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

Show details

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

F0658 Potential Harm Scope/Severity: E

Resident Assessment and Care Planning Deficiencies

Show details

Ensure services provided by the nursing facility meet professional standards of quality.

F0684 Potential Harm Scope/Severity: E

Quality of Life and Care Deficiencies

Show details

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

F0758 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

Show details

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.

F0761 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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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.

F0880 Potential Harm Scope/Severity: D

Infection Control Deficiencies

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Provide and implement an infection prevention and control program.

F0921 Potential Harm Scope/Severity: D

Environmental Deficiencies

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Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

See full violation history →

Staffing

1.14
RN hrs/res/day
0.80
LPN hrs/res/day
3.04
CNA hrs/res/day
4.51
Weekend hrs/res/day
37%
Total nurse turnover
33%
RN turnover

A nurse checks on each resident roughly every 4.8 hours on average.

Fines & Penalties

No fines or penalties on record.

Ownership

Non profit - Church related Independent (not part of a chain)
  • Ownership Data Not Available

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