Inspection Report Summary
The most recent inspection on July 11, 2025, found no deficiencies. Earlier inspections showed a mix of results, with some reports noting deficiencies related to resident care, medication management, and abuse policy implementation. Prior issues included delayed treatment of pressure injuries, failure to report falls, incomplete medication assessments, and inadequate investigation and reporting of abuse allegations. Complaint investigations were mostly unsubstantiated, except for one in September 2023 where the facility failed to investigate and report an abuse allegation properly. The recent clean inspections suggest improvement in compliance compared to earlier findings.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
67 residents
Based on a July 2025 inspection.
Occupancy over time
Inspection Report
Renewal
Census: 67
Deficiencies: 0
Date: Jul 11, 2025
Visit Reason
The inspection was conducted as a renewal of the facility's license to operate.
Findings
The licensing inspector completed a tour of the physical plant, reviewed resident and staff records, and conducted interviews. No violations of applicable standards or laws were found during the inspection.
Report Facts
Number of residents present: 67
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Census: 84
Deficiencies: 0
Date: May 15, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector completed a tour of the physical plant, reviewed resident and staff records, and conducted interviews with residents and staff.
Report Facts
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 15, 2025
Visit Reason
The inspection was conducted as a complaint-related investigation at the assisted living facility Our Lady of Hope.
Complaint Details
The visit was complaint-related as explicitly stated, but no substantiation status or further complaint details are provided.
Findings
The report reviews compliance with 22VAC40-73 Resident Care and Related Services regulations. No specific findings or deficiencies are detailed in the provided document.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tamara Watkins | Inspector | Named as the current inspector conducting the complaint-related inspection. |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 0
Date: May 15, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on May 15, 2025, regarding allegations in the area of Resident Care and Related Services.
Complaint Details
Complaint related to Resident Care and Related Services; the allegations were not substantiated.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No violation notice was issued.
Report Facts
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 6, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including pressure injury care and fall reporting, at Our Lady of Hope Health Center.
Findings
The facility failed to implement and provide appropriate care for a pressure injury for Resident #6, including delayed treatment and incomplete care plan implementation. Additionally, the facility failed to report and follow post-fall procedures for Resident #8, who sustained a fractured femur after an unreported fall.
Deficiencies (3)
Failed to implement the comprehensive care plan to provide treatment to a pressure injury for Resident #6.
Failed to provide care and services to promote healing of a pressure injury for Resident #6, with delayed treatment from 10/28/24 to 11/4/24.
Failed to report a fall and follow post fall procedures for Resident #8, resulting in delayed documentation and investigation of a fractured femur.
Report Facts
Residents in survey sample: 8
Pressure injury size: 3.5
Pressure injury size: 5.5
Pressure injury size: 3.8
Fall date: Aug 28, 2024
Fall report date: Sep 2, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ASM #2 | Director of Nursing | Provided statements regarding care plan implementation failures and fall reporting issues |
| LPN #2 | Licensed Practical Nurse | Interviewed about care plan purpose and fall assessment procedures |
| ASM #1 | Administrator | Made aware of findings and provided statements about fall incident |
| ASM #3 | Assistant Administrator | Made aware of findings |
| CNA #1 | Certified Nursing Assistant | Interviewed about fall risk awareness and reporting procedures |
Inspection Report
Monitoring
Census: 87
Deficiencies: 0
Date: Apr 29, 2024
Visit Reason
The inspection was a monitoring visit conducted to review compliance with various administrative, personnel, resident care, and facility standards.
Findings
The inspection found no violations of applicable standards or laws during the review of the physical plant, resident and staff records, and interviews.
Report Facts
Resident records reviewed: 8
Staff records reviewed: 4
Resident interviews conducted: 2
Staff interviews conducted: 2
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 27, 2023
Visit Reason
The inspection was conducted to investigate allegations of abuse reported by the family of Resident #1, including claims of physical assault and failure to follow abuse reporting policies.
Complaint Details
The complaint involved allegations from Resident #1's son and a Senator's office email dated 9/22/2023, reporting elder abuse including physical assault and disrespectful staff behavior. The facility failed to investigate or report these allegations timely. The resident was discharged before the facility received the email, and no report was made to the State Agency as of 10/2/2023.
Findings
The facility failed to implement its abuse policy by not investigating and reporting an allegation of abuse for Resident #1. The facility also failed to report the allegation to the State Agency. Additionally, the care plan for Resident #1 did not reflect resident-centered preferences regarding no male caregivers due to religious beliefs. For Resident #2, the physician failed to document a progress note explaining the rationale for medication dose change.
Deficiencies (4)
Failed to implement abuse policy for investigating and reporting an allegation of abuse for Resident #1.
Failed to report an allegation of abuse to the State Agency for Resident #1.
Failed to review and revise the care plan to evidence resident-centered preferences for care for Resident #1.
Physician failed to write, sign, and date a progress note during a visit explaining the rationale for lowering medication dose for Resident #2.
Report Facts
Resident sample size: 8
BIMS score: 12
Assessment Reference Date: Aug 25, 2023
Medication dose change date: Jul 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ASM #1 | Executive Director | Interviewed regarding abuse allegations and reporting failures for Resident #1 |
| ASM #2 | Director of Nursing | Interviewed regarding care plan development and accommodation of Resident #1's preference for female caregivers |
| ASM #3 | Physician | Interviewed regarding failure to document rationale for medication dose change for Resident #2 |
| CNA #2 | Scheduling Coordinator | Interviewed about accommodation of Resident #1's request for female caregivers |
| RN #1 | MDS Coordinator | Interviewed about care plan expectations for Resident #1 |
| LPN #3 | Licensed Practical Nurse | Interviewed about staffing and care for Resident #1 |
Inspection Report
Monitoring
Census: 83
Deficiencies: 0
Date: Jun 22, 2023
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review compliance with applicable standards and laws.
Findings
The inspection found no violations with applicable standards or laws. The inspector completed a tour of the physical plant, reviewed resident and staff records, and conducted interviews with residents and staff.
Report Facts
Resident records reviewed: 10
Staff records reviewed: 5
Resident interviews conducted: 6
Staff interviews conducted: 2
Inspection Report
Routine
Deficiencies: 5
Date: May 2, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, resident rights, accurate assessments, care planning, and medication storage at Our Lady of Hope Health Center.
Findings
The facility failed to assess one resident for self-administration of medication, failed to promote a resident's desired bedtime, failed to maintain accurate MDS assessments and care plans related to hospice services for one resident, and failed to secure medications in resident rooms for two residents. Facility policies and staff interviews revealed gaps in medication self-administration assessments and medication storage practices.
Deficiencies (5)
Facility staff failed to assess one resident for self-administration of medication and failed to have physician orders for medications found unsecured in the resident's room.
Facility staff failed to promote a resident's desired bedtime, resulting in delayed assistance to bed.
Facility staff failed to maintain an accurate MDS assessment by not coding hospice services for one resident.
Facility staff failed to develop a comprehensive care plan including hospice services for one resident.
Facility staff failed to secure medications in resident rooms for two residents, including diabetic Tussin, Systane eye drops, and an Albuterol inhaler.
Report Facts
Residents in survey sample: 28
Resident #41 BIMS score: 11
Resident #23 BIMS score: 14
Resident #29 BIMS score: Not explicitly stated, but resident #29 was in hospice
Resident #35 BIMS score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse interviewed regarding medication self-administration and medication storage | |
| ASM #1 | Executive Director interviewed regarding medication self-administration policy and awareness of concerns | |
| ASM #2 | Director of Nursing interviewed regarding medication self-administration assessments and storage | |
| ASM #3 | Assistant Administrator made aware of concerns | |
| RN #2 | Registered Nurse and MDS coordinator interviewed regarding MDS assessments and care plans |
Inspection Report
Renewal
Census: 80
Deficiencies: 3
Date: Jun 3, 2022
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including failure to eliminate environmental hazards in the secure unit, failure to maintain current CPR/AED certification for employees, and failure to maintain the interior building with a medium size hole found in a resident room. Plans of correction were submitted to address these issues.
Deficiencies (3)
Facility failed to take special environmental precautions to eliminate hazards in the secure unit; a metal typewriter was accessible to residents and not secured.
Facility failed to maintain current CPR/AED certification for employees #8 and #6.
Facility failed to maintain the interior building; a medium size hole was found in the wall behind a resident's recliner chair in Room #116.
Report Facts
Number of residents present: 80
Number of resident records reviewed: 10
Number of staff records reviewed: 10
Number of interviews conducted with staff: 3
Inspection Report
Annual Inspection
Capacity: 75
Deficiencies: 5
Date: Dec 9, 2021
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements and evaluate the facility's care and services.
Findings
The facility was found deficient in several areas including failure to review and revise a resident's comprehensive care plan after a fall, improper storage of respiratory equipment for two residents, incomplete annual training records for a certified nursing assistant, and failure to properly store food items in the kitchen.
Deficiencies (5)
Facility staff failed to review and revise the comprehensive care plan for Resident #28 after a fall on 11/14/2021.
Facility staff failed to store nebulizer equipment in a sanitary manner for Resident #28.
Facility staff failed to store an incentive spirometer in a sanitary manner for Resident #62.
Facility failed to ensure CNA #1 received required annual abuse training during the anniversary year 5/16/20 to 5/16/21.
Facility staff failed to dispose of expired food and improperly stored food items in the kitchen dry storage room.
Report Facts
Residents in survey sample: 32
Facility bed capacity: 75
CNA training records reviewed: 5
CNA #1 hire date: May 16, 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding care plan review and nebulizer equipment storage |
| RN #2 | Registered Nurse, MDS Coordinator | Interviewed regarding care plan review and MDS assessment |
| ASM #1 | Executive Director | Interviewed and made aware of findings; provided facility policies |
| OSM #3 | Director of Dining Services | Interviewed regarding food storage and disposal practices |
Inspection Report
Monitoring
Census: 83
Deficiencies: 0
Date: Jun 10, 2021
Visit Reason
A monitoring inspection was initiated due to a state of emergency health pandemic declared by the Governor of Virginia, conducted using an alternate remote protocol.
Findings
The inspection reviewed resident and staff records, medication administration records, activities calendar, staff schedules, health care oversight, and inspection reports, determining no violations with applicable standards or law.
Report Facts
Resident records reviewed: 4
Staff records reviewed: 4
Inspection Report
Routine
Deficiencies: 13
Date: Feb 27, 2020
Visit Reason
The inspection was a routine survey of Our Lady of Hope Health Center to assess compliance with regulatory requirements including resident rights, abuse prevention, care planning, bed safety, dialysis services, respiratory care, and staff training.
Findings
The facility was found deficient in multiple areas including failure to annually review residents' advance directives, incomplete employee background checks, inadequate transfer documentation, failure to complete PASARR screenings prior to admission, incomplete baseline and comprehensive care plans especially regarding bed rail use, failure to provide respiratory care at prescribed oxygen levels, incomplete dialysis communication and contracts, failure to complete annual CNA performance reviews and training, and failure to maintain dumpster area cleanliness and conduct bed safety inspections.
Deficiencies (13)
Failure to evidence documentation of an annual review of residents' advance directives for multiple residents.
Failure to perform timely criminal background checks and obtain references for certain employees.
Failure to evidence transfer discharge requirements and provide written notification to resident or responsible party upon hospital transfer.
Failure to complete PASARR screening prior to admission for residents with mental illness or intellectual disabilities.
Failure to develop complete baseline care plan addressing use of bed rails for a resident.
Failure to implement comprehensive care plans for oxygen therapy and bed rail use for residents.
Failure to review and revise comprehensive care plans to address and include use of bed rails for multiple residents.
Failure to ensure dialysis services were provided consistent with professional standards and failure to maintain communication and contract with dialysis provider.
Failure to implement bed rail requirements including assessment for safety risk, review of risks and benefits, informed consent, and proper installation and maintenance for multiple residents.
Failure to complete annual CNA performance reviews for seven of ten CNA employee records reviewed.
Failure to maintain dumpster area in a clean and sanitary manner to prevent pests.
Failure to inspect beds to identify areas of possible entrapment for multiple residents.
Failure to ensure required annual in-service training for CNAs including dementia management and abuse prevention.
Report Facts
Employee records reviewed: 25
CNA employee records reviewed: 10
Dialysis treatments: 11
Dialysis communication forms missing: 7
BIMS score: 3
BIMS score: 10
BIMS score: 1
BIMS score: 12
BIMS score: 12
BIMS score: 13
BIMS score: 14
BIMS score: 12
BIMS score: 1
Oxygen liters per minute: 3
Oxygen concentrator setting: 2.5
Employee hire date: 2005
Employee hire date: 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ASM #1 | Administrator | Interviewed regarding advanced directives, transfer documentation, bed rail evaluations, and CNA performance reviews |
| ASM #2 | Director of Nursing | Interviewed regarding advanced directives, transfer documentation, dialysis communication, bed rail evaluations, and CNA performance reviews |
| OSM #1 | Acting Director of Admissions, Business Office and Human Resources | Interviewed regarding employee background checks and references |
| OSM #3 | Director of Maintenance | Interviewed regarding bed safety inspections, maintenance of bed rails, and dumpster area cleanliness |
| OSM #4 | Director of Social Services | Interviewed regarding advanced directives and PASARR completion |
| OSM #5 | Director of Admissions | Interviewed regarding advanced directives and PASARR completion |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding advanced directives, transfer documentation, dialysis communication, bed rail assessments, and oxygen therapy |
| LPN #5 | Licensed Practical Nurse | Interviewed regarding transfer documentation and dialysis communication |
| LPN #6 | Licensed Practical Nurse | Interviewed regarding dialysis communication |
| LPN #7 | Licensed Practical Nurse | Mentioned in employee background check deficiency |
| RN #1 | Quality Assurance Nurse | Interviewed regarding advanced directives, transfer documentation, bed rail evaluations, and oxygen therapy |
| RN #2 | Registered Nurse | Interviewed regarding advanced directives, bed rail assessments, and oxygen therapy |
| RN #4 | Registered Nurse | Interviewed regarding bed rail use and care plan |
| CNA #8 | Certified Nursing Assistant | Employee record reviewed for background check deficiency |
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