Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Our Lady Of Hope Health Center during CMS and state inspections, most recent first.
A resident with intact cognition did not receive a physician-ordered fish oil supplement because the medication was not available on multiple occasions. The MAR documented the doses as unavailable, nursing notes stated the medication was not available, and the backup supply list showed it was not stocked. An LPN stated staff should check emergency supply, call the pharmacy, and notify the physician and RP when a medication is unavailable, and the facility policy required immediate action to obtain the medication from the pharmacy.
Unsanitary Dumpster Area: The facility failed to maintain the dumpster area in a sanitary manner. An observation found debris behind the dumpsters, including a plastic garbage bag with trash, loose medical gloves, and a nail clipper on the ground. The maintenance director stated the area was maintained by janitors and was also a team effort with kitchen and dietary staff, and he agreed the area needed cleaning. The facility’s infection control policy required garbage to be placed into containers as soon as possible and for control measures to eliminate insects and rodents.
Kitchen Sanitation and Food Storage Deficiencies: Surveyors found expired thickened dairy beverage in dry storage, lentils stored in a bin with part of the product label placed on top of the food, debris on food prep equipment, wet nesting among cleaned steam tray pans, and dust on a utility fan. The dietary manager acknowledged the expired product, the need to clean the appliances, and the need to clean the fan.
Two residents experienced medication-related deficiencies when staff did not follow professional standards. In one case, an LPN opened an extended-release Tolterodine capsule and mixed its contents with other crushed medications for a cognitively impaired resident, despite facility drug references stating that extended-release capsules must be swallowed whole. In the other case, a cognitively intact resident with chronic pain did not receive ordered Tramadol doses as scheduled, even though the drug was available in Omnicell, and several subsequent Tramadol doses were administered well outside the accepted 1-hour before/after window. Staff interviews revealed reliance on pharmacy coding practices, delayed MAR documentation for narcotics, and acknowledgment by nursing leadership that these practices did not meet professional standards or the facility’s own medication administration policy.
Two residents experienced deficiencies in clinical documentation and medication records. One resident with chronic pain and multiple comorbidities had Tramadol ordered four times daily, but the MAR showed missed and significantly delayed doses while the narcotic sign-out sheet reflected pulls at scheduled times, and the resident reported frequent delays in pain medication. LPNs described pharmacy-related barriers to obtaining narcotics and acknowledged delayed MAR documentation, and the ADON confirmed this did not meet professional standards for complete and accurate records. Another resident with pneumonia, sepsis, acute respiratory failure, and CHF had documented respiratory decline and provider orders, but there was no progress note or eINTERACT form for the hospital transfer, and the DON stated there was no evidence of clinical documentation sent with the resident.
A resident with PNA, sepsis, acute respiratory failure, and CHF was transferred to the hospital for SOB and functional decline, but the facility had no evidence of a progress note or eINTERACT form documenting the transfer. The DON confirmed there was no clinical documentation sent with the resident, despite the facility policy requiring transfer information such as practitioner contact details, representative information, advance directives, care plan goals, and other necessary records.
A resident’s ordered Fish Oil oral supplement was not administered on two occasions because the medication was not available. The MAR documented an alternate code instead of administration, and nurses’ notes stated the medication was not available. Review of the backup supply list showed the medication was not stocked, and the resident, who was cognitively intact per BIMS, stated there was a problem with receiving medications at the facility.
A resident with moderate cognitive impairment and use of antipsychotic medication had a pharmacy review recommending a GDR of quetiapine, and the MD accepted the recommendation. However, the order was not implemented in a timely manner, with the med still given daily for days after approval before the frequency was briefly changed and then returned to the prior dose after the RP requested the resident stay on the current regimen.
Failure to Administer Consented COVID-19 Vaccines: The facility failed to complete the COVID-19 immunization process for two residents after consent and education were documented. Both residents had COVID-19 vaccines listed as past due and pending, but the record did not show administration. The IP stated the vaccines were thought to be unavailable at the time and then fell through the cracks after the former IP resigned.
Failure to Post Daily Direct Care Staffing Information: The facility did not visibly post the daily direct care staffing information in the lobby, outside the nursing care center, or at the nursing station during survey observations. The DON stated the information was kept in a book and was not posted because a plastic frame was needed. The facility policy required daily posting of licensed and unlicensed direct care staff, facility name, current date, and resident census at the beginning of the shift.
A resident with a pressure injury did not receive the necessary treatment as outlined in their comprehensive care plan. The injury was first observed by therapy staff, but the treatment was not documented in the eTAR until several days later due to an entry error. Interviews with facility staff revealed that the care plan was not properly implemented, leading to a lack of awareness about the required treatment.
A resident developed a deep tissue injury (DTI) on the right heel, first observed by therapy staff, but the facility failed to document treatment until several days later. The eTAR showed heel floating but lacked specific treatment documentation until November. Interviews revealed a documentation error, as an order for skin prep was misplaced, preventing staff from knowing the treatment was needed.
A resident with a history of falls and fractures experienced an unreported fall, leading to a delayed diagnosis of a femur fracture. The LTC facility staff failed to follow post-fall procedures, including immediate assessment, documentation, and notification of the physician. The incident was only discovered during an investigation into the injury, highlighting a lapse in protocol adherence.
Medication Not Available for Ordered Supplement
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when facility staff failed to obtain and administer the physician-ordered Fish Oil Oral Capsule 1000 mg for one resident. The resident had an order dated 4/8/26 for Fish Oil Oral Capsule 1000 mg once daily as a supplement, and the June 2026 MAR documented the same order. On 6/2/26 and 6/7/26, the MAR coded the medication as 9=Other/See Progress Notes, and nursing notes documented that the medication was not available. A review of the facility backup medication supply list showed the medication was not stocked in supply. The resident, who had a BIMS score of 15 out of 15 on the most recent MDS and was cognitively intact for daily decisions, stated there was a problem with receiving medications at the facility and that they did not understand it. An LPN stated medications should be reordered from the pharmacy when seven pills remain and that when a medication is not available, staff should check emergency supply, call the pharmacy, and notify the physician and RP. The facility policy stated that upon discovery of inadequate medication to administer to a resident, staff should immediately initiate action to obtain the medication from the pharmacy.
Unsanitary Dumpster Area
Penalty
Summary
The facility failed to maintain one of one dumpster area in a sanitary manner. During an observation of the dumpster area behind the facility with the dietary manager, debris was seen collected behind the dumpsters, including a plastic garbage bag with trash inside, multiple loose medical gloves, and a nail clipper on the ground. During a later observation and interview, the maintenance director stated that janitors maintained the area, but that it was also a team effort with kitchen and dietary staff and should be done daily with a deep clean at least once a week; he agreed the dumpster area needed cleaning. The facility's Food Services Infection Control policy, revised 7/14/25, stated that garbage and waste should be placed into containers as soon as possible and that appropriate control measures should be used to eliminate insects and rodents. The Administrator, DON, and Infection Preventionist were informed of the findings.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner. During an observation of the kitchen, surveyors found two 32-oz cartons of thickened dairy beverage in dry storage with a use-by date of 8/14/25, a 12-quart plastic bin dated 3/6/26 containing less than 1 quart of lentils with a portion of the product label placed on top of the lentils, and debris that could be scraped or wiped away inside the mixing bowl, around the base of the stand mixer, and around the base of the deli slicer. The dietary manager was present during the observation and acknowledged that the expired cartons should not have been available for use and that the appliances needed to be cleaned. Surveyors also observed twelve cleaned steam tray pans stacked ready for use, with the third pan wet on the outside and droplets of water observed on the inside and outside of the pan, which the dietary manager identified as wet nesting. In addition, a large utility fan on the kitchen floor had visible dust on the front and back of the fan cage. The dietary manager stated the fan needed to be cleaned. The facility's Food Services Infection Control policy required food supplies and equipment to meet accepted standards of safety and sanitation, periodic checking of food items for expiration dates, thorough washing and drying of utensils and food contact surfaces, and proper installation and maintenance of equipment.
Failure to Follow Professional Standards in Medication Administration and Pain Management
Penalty
Summary
Facility staff failed to follow professional standards of practice during medication administration for two residents. For one resident with an overactive bladder and severe cognitive impairment (BIMS score of 6/15), an LPN prepared the morning medications, which included Zinc, Ascorbic Acid, Tolterodine Tartrate ER 4 mg, and Pro-Stat. After the resident stated the medications were too large to swallow, the LPN offered to crush them. The LPN then crushed the Ascorbic Acid tablet and opened both the Zinc and Tolterodine Tartrate ER capsules, emptying their contents into a medication cup and administering the mixture to the resident, who consumed all three medications. The physician’s order specified Tolterodine Tartrate as an extended-release oral capsule to be given once daily, and the facility’s drug reference (Nursing 2025–2026 Drug Handbook) explicitly instructed that extended-release Tolterodine capsules are to be swallowed whole and not crushed or opened. In a subsequent interview, the LPN stated she uses a guide on the medication cart to determine which medications can be crushed or opened, acknowledged that extended-release medications should not be crushed or opened, and admitted she should not have opened the Tolterodine capsule. For another resident with diagnoses including chronic pain, spondylosis, bipolar disorder, anxiety disorder, and diabetes mellitus, the facility did not administer ordered pain medication in accordance with professional standards. The resident was cognitively intact (BIMS 15/15) and required assistance with mobility and hygiene. The comprehensive care plan identified chronic pain related to spondylosis and directed staff to administer pain medications per order if non-medication interventions were ineffective. Physician orders dated 4/8/26 prescribed Tramadol 50 mg by mouth four times a day for chronic pain. Progress notes documented that on the evening of admission, the Tramadol order was a new admit medication that was not available, with the provider aware, and a subsequent note identified a duplicate order. The MAR showed that Tramadol doses scheduled for the evening of admission and the following morning were not administered, despite the facility’s Omnicell inventory list showing Tramadol 50 mg available in stock. The same resident’s Tramadol was also not administered within the prescribed time frame on multiple occasions. The narcotic sign-out sheet showed Tramadol was removed from Omnicell at the scheduled administration times of 10:00 a.m., 1:00 p.m., 6:00 p.m., and 10:00 p.m., but the MAR documented delayed administration for several doses: one evening dose given 2.5 hours late, another evening dose 1.5 hours late, a midday dose 2.75 hours late, and another evening dose 1.75 hours late. The resident reported that pain medication was frequently delayed. An LPN described that when the pharmacy receives prescriptions for narcotics, they do not provide a code to pull from Omnicell, and that non-pharmacological interventions and non-narcotic medications were used instead. Another LPN stated that scheduled medications are to be given within one hour before or after the scheduled time. The assistant DON confirmed that, based on nurse statements, narcotics were signed out in the narcotic book but not signed off in the MAR until later, and acknowledged this did not follow professional standards, which require medications—especially narcotics—to be signed off immediately. The facility’s Medication Administration policy required medications to be administered within one hour before or after the scheduled time, with documentation in the MAR or eMAR occurring immediately after administration and not delayed or completed in advance.
Incomplete and Inaccurate Clinical Documentation for Pain Management and Hospital Transfer
Penalty
Summary
The deficiency involves failures in maintaining complete, accurate, and timely medical records and documentation for two residents. For one resident with chronic pain, spondylosis, bipolar disorder, anxiety disorder, and diabetes mellitus, the care plan called for opioid medication for pain management, including Tramadol 50 mg four times daily for chronic pain. Progress notes documented that the Tramadol order was a new admission medication and that a duplicate order existed. The MAR showed that Tramadol doses scheduled for the evening of admission and the following morning were not administered, and subsequent doses on multiple days were administered outside the facility’s stated one-hour-before/one-hour-after window. The resident reported that pain medication was frequently delayed. Nursing staff interviews revealed inconsistencies between narcotic pull documentation and MAR entries. LPNs reported that when the pharmacy had not yet delivered Tramadol or had not provided an Omnicell code for narcotics, they implemented non-pharmacological and non-narcotic interventions instead. A review of the narcotic sign-out sheet for Tramadol showed pulls at scheduled administration times, while the MAR reflected delayed administrations on several dates and times. The assistant director of nursing acknowledged that nurses signed out narcotics in the narcotic book but did not document administration in the MAR until later, and confirmed this did not follow professional standards of practice and did not constitute a complete and accurate medical record. For a second resident with pneumonia, sepsis, acute respiratory failure, and CHF, who was severely cognitively impaired and required maximal assistance for mobility and ADLs, the baseline care plan included monitoring respiratory status. A progress note documented functional decline with shortness of breath and cough, and the primary care provider’s recommendations for a STAT chest x-ray and medications were recorded. However, there was no evidence in the medical record of a progress note or eINTERACT form documenting the resident’s transfer to the hospital, and the DON stated there was no evidence of clinical documentation sent with the resident to the hospital. These omissions demonstrated a failure to maintain required clinical documentation related to the hospital transfer.
Missing Transfer Documentation for Hospitalized Resident
Penalty
Summary
Facility staff failed to provide evidence of required clinical documentation after a resident was transferred to the hospital. Resident #75 was transferred to the hospital for shortness of breath and functional decline, and the resident’s record showed diagnoses including pneumonia, sepsis, acute respiratory failure, and CHF. The resident’s most recent MDS coded a BIMS score of 6 out of 15, indicating severe cognitive impairment, and Section GG showed the resident required maximal assistance for mobility, transfers, bathing, dressing, and hygiene. The baseline care plan identified ineffective airway clearance, upper respiratory infection, pneumonia, shortness of breath, and respiratory failure, with interventions to evaluate respiratory rate, effort, cough, and shortness of breath. The progress note documented shortness of breath and cough, and the PCP responded with recommendations for a STAT chest x-ray, Mucinex, and Tylenol. However, there was no evidence of a progress note or eINTERACT form documenting the hospital transfer, and the DON stated there was no evidence of clinical documentation sent with the resident to the hospital. The facility’s Transfer-Discharge Process policy required information to be provided to the receiving provider, including practitioner contact information, resident representative information, advance directive information, special instructions or precautions, comprehensive care plan goals, and other necessary documentation for a safe and effective transition of care.
Medication Not Available for Resident’s Ordered Supplement
Penalty
Summary
The facility failed to provide the physician-ordered Fish Oil Oral Capsule 1000 mg for one resident on two occasions. The resident had an order dated 4/8/26 for Fish Oil Oral Capsule 1000 mg once daily as a supplement, and the June 2026 MAR showed the same order. On 6/2/26 and 6/7/26, the MAR documented code 9, meaning Other/See Progress Notes, instead of administration of the medication. Nurses’ notes for those dates documented that the medication was not available. Review of the facility backup medication supply list showed the Fish Oil Oral Capsule was not stocked in supply. The resident was interviewed and stated there was a problem with receiving medications at the facility and that they did not understand it. The resident’s most recent MDS, with ARD 4/13/26, showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact for daily decision-making.
Delayed Implementation of Pharmacy Medication Review Recommendation
Penalty
Summary
The facility failed to act in a timely manner on a pharmacy medication regimen review for one resident. The resident’s MDS admission assessment dated 3/17/2026 showed moderate impairment in daily decision-making and indicated the resident was receiving antipsychotic, antidepressant, anticoagulant, and antibiotic medications. A pharmacy consultation report dated 3/16/2026 recommended a gradual dose reduction of Quetiapine from 12.5 mg every other night at bedtime for 7 days, then discontinuation, and the physician signed acceptance of the recommendation on 3/19/2026. Despite the physician’s approval, the resident’s eMAR documented Quetiapine 12.5 mg administered daily at bedtime through 3/31/2026 and continued daily through 4/8/2026. The order was not changed to every other day until 4/9/2026, and it was discontinued on 4/10/2026 with a new order returning the medication to the original daily bedtime dose. Progress notes documented that the pharmacy recommendation and GDR were discussed, that the responsible party was aware, and that the responsible party later requested the resident remain on the current dose. The facility policy stated that the attending physician should document in the resident’s record that the identified irregularity has been reviewed and what action, if any, was taken to address it.
Failure to Administer Consented COVID-19 Vaccines
Penalty
Summary
The facility failed to implement a complete immunization program for two residents by not administering the COVID-19 vaccine after consent had been documented. For Resident #1, the clinical record showed COVID-19 Moderna booster immunization was pending, consent was confirmed, and education was provided, but the record did not show that the vaccine was actually administered. A vaccination summary also documented COVID-19 as past due, and a nursing facility influenza/pneumonia vaccines document recorded consent for the COVID-19 monovalent vaccine. For Resident #12, the clinical record similarly showed a pending COVID-19 Moderna booster with consent confirmed and education provided, while the vaccination summary documented COVID-19 as past due. A nursing facility influenza/pneumonia vaccines document recorded consent for the COVID-19 monovalent vaccine, but the record did not evidence administration of the vaccine after consent was given. During interview, the infection preventionist stated both residents had consented in the fall, but the vaccine was thought not to have been in stock at that time and then was not administered after the former infection preventionist resigned.
Failure to Post Daily Direct Care Staffing Information
Penalty
Summary
The facility failed to post the daily direct care staffing information on 4/14/26. During survey observations at 8:00 AM, 11:00 AM, and 3:30 PM, there was no evidence of staff posting in the main lobby, the lobby outside the nursing care center, or on the nursing station desk in the nursing care center. The Director of Nursing stated at 3:45 PM that the staffing information was in a book and was not posted because a plastic frame was needed. The facility’s Posting of Direct Care Staff policy stated that the number of licensed and unlicensed direct care staff, facility name, current date, and resident census were to be posted daily at the beginning of the shift. The staffing information was posted correctly on the remaining days reviewed.
Failure to Implement Comprehensive Care Plan for Pressure Injury
Penalty
Summary
The facility staff failed to implement the comprehensive care plan for a resident, identified as Resident #6, who had a pressure injury. The resident was assessed with an unstageable deep tissue injury (DTI) on the right heel, which was not present upon admission. The care plan documented the resident's risk for pressure ulcers due to various factors, including impaired mobility and fragile skin. Despite the care plan's documentation, the treatment for the right heel DTI was not implemented as required. The progress notes indicated that the DTI was first observed on October 28, 2024, and a consult was put in place for the resident to be seen by a wound physician. However, the electronic treatment administration record (eTAR) did not show any treatment for the right heel DTI until November 4, 2024, when Betadine treatment began. The skin prep treatment was documented to start on November 7, 2024. The director of nursing confirmed that an order for skin prep was placed on November 1, 2024, but it was not reflected in the eTAR due to an entry error. Interviews with facility staff revealed that the care plan was not properly implemented, as the order for the treatment was not entered correctly, leading to a lack of awareness among staff about the necessary treatment. The facility's policy on comprehensive person-centered care planning emphasized the importance of developing and implementing a care plan to meet the resident's needs, but this was not adhered to in the case of Resident #6.
Failure to Provide Timely Pressure Ulcer Treatment
Penalty
Summary
The facility staff failed to provide adequate care and services to promote the healing of a pressure injury for one resident, identified as Resident #6. The deficiency was noted when a deep tissue injury (DTI) on the resident's right heel was first observed on October 28, 2024, but no treatment was documented until November 4, 2024. The resident's medical records indicated that the DTI was not present upon admission, and the injury was first noted by therapy staff who communicated the need for heel protection. Despite this, there was a delay in obtaining and documenting a treatment order for the DTI. The facility's electronic treatment administration record (eTAR) for October 2024 showed that the resident's heels were floated when in bed starting on October 28, 2024, but it did not document any specific treatment for the right heel DTI until November 4, 2024. The eTAR for November 2024 indicated that Betadine was applied to the right heel from November 4 to November 7, 2024, and a skin prep treatment began on November 7, 2024. The comprehensive care plan for the resident, updated on October 31, 2024, acknowledged the risk for pressure ulcers due to various factors, including impaired mobility and a DTI on the right heel. Interviews with facility staff revealed that there was a communication and documentation error. The director of nursing acknowledged that an order for skin prep was placed on November 1, 2024, but it was incorrectly entered into the system, preventing it from appearing on the eTAR. This oversight meant that staff were unaware of the treatment requirement. The facility's policy on pressure ulcer and skin care required obtaining a treatment order and documenting nursing interventions, which was not followed in this instance.
Failure to Report and Follow Post-Fall Procedures
Penalty
Summary
The facility staff failed to report and follow post-fall procedures for a resident who experienced a fall on the evening shift. The incident was not documented until several days later, after the resident was found to have a fractured femur and an investigation into the injury was initiated. The resident, who had a history of multiple fractures, repeated falls, and other health issues, was not assessed for injuries immediately following the fall, and the necessary documentation and notifications were not completed in a timely manner. The resident was admitted with existing pelvic fractures and was identified as a high fall risk. Despite this, the fall that occurred was not reported or documented until after the resident began complaining of pain and was subsequently found to have a new fracture. The nursing staff failed to conduct a post-fall assessment, notify the physician, or update the care plan as required by the facility's policy. This lack of immediate action and documentation delayed the identification and treatment of the resident's injury. Interviews with facility staff revealed that the fall was only discovered during an investigation into the fracture, and the staff involved in the incident were no longer employed at the facility. The director of nursing acknowledged that the fall was not reported or investigated as it should have been, and that the staff had not been fully educated on the proper procedures. The facility's policy required a comprehensive post-fall evaluation and intervention, which was not followed in this case.
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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 Richmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shalom Gardens Health & Rehabilitation | 2.4 mi | ★★★★★ | 8 | 2 |
| Canterbury Rehabilitation And Healthcare Center | 2.7 mi | ★★★★★ | 23 | 3 |
| Lakewood Manor | 3.2 mi | ★★★★★ | 0 | 0 |
| Cedarfield Pinnacle Living | 3.2 mi | — | 0 | 0 |
| The Laurels Of University Park | 3.9 mi | ★★★★★ | 0 | 0 |
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