5 Reports · 1 Summary
Inspection Summary
8 inspections covered, Jun 2021 – Jul 2025.
Inspection Reports Summary
Visit Reason
This report covers 8 inspections of Our Lady of Hope from June 10, 2021 to July 11, 2025, including 2 complaint surveys.
Complaint Details
Two inspections were prompted by complaints regarding Resident Care and Related Services; both found no violations.
Findings
Across that history VDSS cited 3 violations under 3 distinct standards. 1 of 8 visits ended with violations cited and 7 with none.
Violations (3)
22VAC40-73-1180-A: Facility failed to take special environmental precautions in secure unit.
22VAC40-73-870-A: Facility failed to maintain the interior building.
22VAC40-73-260-A: Facility failed to maintain current CPR/AED certification for employees.
Report Facts
Violations cited: 3
Distinct standards: 3
Inspections on page: 8
Inspections with violations: 1
Complaint visits: 2
Individual Reports
One document per inspection visit.
Inspection Report — Dec 6, 2024
Annual Inspection
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.
Violations (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 — Sep 27, 2023
Complaint Investigation
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.
Violations (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 — May 2, 2023
Routine
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.
Violations (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 — Dec 9, 2021
Annual Inspection
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.
Violations (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
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 — Feb 27, 2020
Routine
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.
Violations (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 |
5 CMS Surveys
CMS Survey — Sep 27, 2023
Sep 27, 2023
CMS Survey — Dec 6, 2024
Dec 6, 2024
CMS Survey — Feb 27, 2020
Feb 27, 2020
CMS Survey — Dec 9, 2021
Dec 9, 2021
CMS Survey — May 3, 2023
May 3, 2023
Loading inspection reports...
