Uva Health Culpeper Medical Center
An acute care hospital in Culpeper, Virginia 22701
501 Sunset Lane, Culpeper, Virginia 22701. (703) 829-4300.
- Medicare payments cut under the HAC Reduction Program (fiscal year 2026)
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The short answer
Record last released by CMS on Oct 20, 2026.
- 2of 5 CMS’s overall rating
- 2of 5 patient survey rating
- 2 deficiencies cited in the last three years
- 70 beds
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Jul 28, 2026: a complaint inspection.
2 deficiencies cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
2 deficiencies in 2 months of the last 36. Last cited Jul 2026. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Jul 28, 2026: complaint inspection1 deficiency
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Supervision Of Contract Staff
The inspectors’ words, 491 words
“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 42929 Based on review of medical records (MR), review of documents, and interviews with staff (EMP) it was determined the facility staff failed to reassess pain within two (2) hours of interventions as per facility policy for one (1) of three (3) patients who received interventions for pain, MR6. Findings: Review of facility document “Pain Assessment and Management” last revised July 2025 reads in part: “... B. Pain Reassessment: 1. Pain will be reassessed within two hours of interventions and ongoing as appropriate to evaluate effectiveness and to recognize undesirable side effects and documented in the medical record....” Review of the medical record revealed patient (MR) 6 was administered fentanyl (medication used to manage breakthrough pain - drugs.com) 50 mcg on May 22, 2026, at 10:55 PM for nine (9) out of ten (10) pain. The next pain reassessment was documented over three (3) hours later on May 23, 2026, at 2:43 AM. Review of the medical record revealed MR6 was administered oxycodone (medication used to manage severe pain severe enough to require an opioid pain medicine when other pain medicines do not treat pain well enough, or are not tolerated - drugs.com) immediate release tablet 10 mg on May 25, 2026, at 9:37 AM for nine (9) out of ten (10) pain. The next pain reassessment was documented over four (4) hours later on May 25, 2026, at 2:21 PM. Review of the medical record revealed MR6 was administered oxycodone immediate release tablet 5 mg on May 25, 2026, at 4:58 PM, and there was no documentation of pain assessment at that time. The next pain reassessment was documented over four (4) hours later on May 25, 2026, at 9:22 PM. Review of the medical record revealed MR6 was administered oxycodone immediate release tablet 10 mg on May 26, 2026, at 9:11 AM for eight (8) out of ten (10) pain. The next pain reassessment was documented over five (5) hours later on May 26, 2026, at 2:53 PM. Review of the medical record revealed MR6 was administered oxycodone immediate release tablet 10 mg on May 26, 2026, at 2:53 PM for eight (8) out of ten (10) pain. The next pain reassessment was documented six (6) hours later on May 26, 2026, at 8:50 PM. Interview on July 28, 2026, in the afternoon, EMP1 indicated that pain must be reassessed and documented within two (2) hours after an intervention such as administration of pain medication as per facility policy.”
Dec 13, 2023: complaint inspection1 deficiency
-
Supervision Of Contract Staff
The inspectors’ words, 624 words
“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 42929 Based on observations, interviews, and document review, it was determined the facility staff failed to obtain an order for the insertion of a nasogastric tube, and properly document the size and person who placed the nasogastric tube as per facility policy for two (2) of three (3) patients sampled. Findings: A review of the emergency department (ED) provider note for Patient #4 (P4) from 9/8/2023 at 6:17 p.m. contained documentation that the on-call surgeon “recommended placement of a NG tube,” and at 6:30 p.m. the documentation “Nursing staff to place NG tube,” and then “KUB (abdominal kidney, ureter, bladder x-ray)ordered for NG placement.” A review of the Event Log contained the documentation on 9/8/2023 at 8:00 p.m. “... NG/OG Tub Nasogastric: Left nostril Placed ... Tube Type: Nasogastric. Tube Location: Left nostril. Catheter Depth (cm): 60 cm. Placement Verification Method: X-ray. Securing Method: Tape ...” No documentation of the size NG tube inserted, as per the facility’s policy. A review of the medical record for P4 contained no evidence of a physician’s order for a nasogastric tube placed in the emergency department on 9/8/2023 at 8:00 p.m. A review of the medical record for P6 contained no evidence of a physician’s order for a nasogastric (NG) tube placed in the emergency department. There was a provider note stating that the NG tube had been placed in the emergency department. There was no note to indicate who placed the NG tube. SM1 was aware of the lack of orders for P4 and P6 above. A review of the facility’s policy titled “Medical Orders for Patient Care” states in part: ... Policy: ... B. Orders shall be: 1. Obtained prior to performing all procedures and/or treatments; 2. Documented in a patient’s electronic health record (EHR). 3. Dated, timed and signed by the ordering Practitioner or another Practitioner who is responsible for the care of the patient only if such provider is acting in accordance with Virginia law, facility policies, and the Medical Staff Bylaws. 4. Dated and time stamped electronically by the electronic health record (EHR) system; 5. Acknowledged and verified by appropriate licensed Team Members (when indicated). 6. Implemented promptly and within the timeframe specified. ... Appendix A ... #7 Verbal with Read Back (Verbal Orders) Verbal Orders must be relayed by the ordering Practitioner, either in person or by telephone, to an Authorized Person. Verbal Orders must be cosigned promptly by the Practitioner no more than [seventy-two] 72 hours after the order is entered. Verbal Orders are to be used infrequently ... A review of the facility’s policy titled “Lippincott Procedures: Nasogastric or Orogastric Tube Insertion” states in part: ... A practitioner selects the type and diameter of NG or OG tube that best meets the patient’s needs. ... Implementation Verify the practitioner’s order. ... Documentation Documentation associated with NG or OG tube insertion includes: type and size of the NG or OG tube, date and, time of insertion, insertion route, tube’s external length measurement and centimeter mark, methods used to confirm tube placement, type and amount of suction (if used), drainage: amount, color, character, consistency, odor, patient’s tolerance of the procedure, signs and symptoms of complications: nausea, vomiting, abdominal distention ... The above concerns were discussed at the exit conference on 12/13/2023.”
All 3 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Jul 28, 2026 | Complaint inspection | 1 deficiency cited |
| Mar 19, 2025 | Complaint inspection | No deficiencies cited |
| Dec 13, 2023 | Complaint inspection | 1 deficiency cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 2 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 6; safety of care, 0 better and 0 worse of 3; readmission, 0 better and 1 worse of 8.
- Patients rate it 2 of 5 in CMS’s patient survey (550 surveys completed, Oct 1, 2024 to Sep 30, 2025): 60% rated it 9 or 10 out of 10, and 61% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): catheter urinary tract infections (CAUTI), no different than national benchmark; surgical site infections after colon surgery, no different than national benchmark; C. diff infections, better than the national benchmark.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart failure 10.9%, pneumonia 15.3%, COPD 8.2%, stroke 12.8%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart failure 22.4%, pneumonia 18.7%, COPD 20.4%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; hospital admissions after outpatient chemotherapy, no different than the national rate; emergency visits after outpatient chemotherapy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 158 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 1% left before being seen.
- 54% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
- Medicare’s spending per patient here is 1.02 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 2 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 2 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Jul 1, 1966.
- Ownership: voluntary non-profit - private.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- Voluntary non-profit - Private.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- CMS cut its Medicare payments by 1% for fiscal year 2026 under the Hospital-Acquired Condition Reduction Program, which does so for the quarter of hospitals that fare worst on conditions patients get in hospital.
- 2 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
| Date | What | Detail |
|---|---|---|
| Medicare payment reduction (HAC Reduction Program) | Fiscal year 2026: 1% of Medicare payments |
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 3 of 5.
- 93% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Uva Community Health Inc. owns 100% directly since Jul 1, 2021.
- Rector & Visitors of the University of Virginia runs it.
- 5 owners or officers are people: Charles Coder (managing employee (under contract)); Charles Coder (corporate officer); Charles Coder (corporate director); Charles Coder (runs it (operational or managerial control)); Sara White (managing employee (on the payroll)).
- CMS’s Provider of Services file records no change of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Rector & Visitors of the University of Virginia | Owns 5% or more through other companies | 100% | Jul 1, 2021 |
| Rector & Visitors of the University of Virginia | Runs it (operational or managerial control) | 100% | Jul 1, 2021 |
| Uva Community Health Inc. | Owns 5% or more directly | 100% | Jul 1, 2021 |
How does it compare nearby?
- No other hospital CMS lists is in Culpeper County.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.