Cycle 1
Health 2023-05-03 · Fire 2023-05-03
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Richmond, VA
Our Lady Of Hope Health Center
4-star overall rating with 4-star inspections with 5 recent health deficiencies
13700 North Gayton Road, Richmond, VA
(804) 360-1960
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
75
Certified beds
Average residents
70
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.68
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.27
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
4.36
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.95
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.69
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
4.52
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
72%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
74%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,218
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.1
Composite VBP score used to determine payment impact.
Payment multiplier
0.9825
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.64
Baseline 17.37% · Performance 19.75% · Measure score 3.64 · Achievement 3.64 · Improvement 0
Healthcare-associated infections
2.9
Baseline 7.42% · Performance 6.97% · Measure score 2.9 · Achievement 2.9 · Improvement 1.37
Total nurse turnover
0
Baseline 65.08% · Performance 69.56% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.91
Baseline 3.09 hours · Performance 3.62 hours · Measure score 1.91 · Achievement 1.91 · Improvement 1.46
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.49% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 478 · Observed rate 9.21% · Lower 95% interval 9.07% |
| Discharge to community | 68.52% |
50.57%
17.9 pts better
|
Better than the National Rate · Eligible stays 470 · Observed rate 68.51% · Lower 95% interval 64.93% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 95.99% |
95.27%
0.7 pts better
|
Numerator 287 · Denominator 299 |
| Falls with major injury | 1.34% |
0.77%
0.6 pts worse
|
Numerator 4 · Denominator 298 |
| Discharge self-care score | 60.59% |
53.69%
6.9 pts better
|
Numerator 123 · Denominator 203 |
| Discharge mobility score | 65.52% |
50.94%
14.6 pts better
|
Numerator 133 · Denominator 203 |
| Pressure ulcers or injuries, new or worsened | 3.68% |
2.29%
1.4 pts worse
|
Numerator 11 · Denominator 299 · Adjusted rate 3.13% |
| Healthcare-associated infections requiring hospitalization | 6.97% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 327 · Observed rate 5.2% · Lower 95% interval 4.67% |
| Staff COVID-19 vaccination coverage | 28.87% |
8.2%
20.7 pts better
|
Numerator 56 · Denominator 194 |
| Staff flu vaccination coverage | 20.59% |
42%
21.4 pts worse
|
Numerator 42 · Denominator 204 |
| Discharge function score | 68.47% |
56.45%
12 pts better
|
Numerator 139 · Denominator 203 |
| Transfer of health information to provider | 97.83% |
95.95%
1.9 pts better
|
Numerator 90 · Denominator 92 |
| Transfer of health information to patient | 98.84% |
96.28%
2.6 pts better
|
Numerator 171 · Denominator 173 |
| Resident COVID-19 vaccinations up to date | 52.41% |
25.2%
27.2 pts better
|
Numerator 76 · Denominator 145 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.5
1 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.9 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.4
0.3 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.8 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.3% |
91.2%
1.1 pts better
|
93.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.3% · Q3 94.4% · Q4 75.8% · 4Q avg 92.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 83.3% |
94.0%
10.7 pts worse
|
95.5%
12.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 83.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
3.6%
2 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 5.4% · Q3 5.6% · Q4 9.1% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
15.7%
15.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 14.4% |
5.7%
8.7 pts worse
|
5.4%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 21.4% · Q3 17.9% · Q4 7.7% · 4Q avg 14.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.7% |
20.2%
8.5 pts better
|
19.6%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 11.8% · Q3 10.3% · Q4 11.5% · 4Q avg 11.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.9% |
15.0%
1.9 pts worse
|
16.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 17.4% · Q3 16.7% · Q4 18.2% · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 38.1% |
17.5%
20.6 pts worse
|
16.3%
21.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 38.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.1% |
15.7%
1.4 pts worse
|
14.9%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 27.6% · Q3 15.4% · Q4 13.0% · 4Q avg 17.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.0% |
0.5%
2.5 pts worse
|
1.0%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 6.5% · Q3 3.5% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 11.9% |
1.6%
10.3 pts worse
|
1.7%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 9.7% · Q3 5.7% · Q4 18.2% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.0% |
22.2%
6.2 pts better
|
19.8%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 14.7% · Q3 12.9% · Q4 17.2% · 4Q avg 16.0% |
| Percentage of long-stay residents with pressure ulcers | 11.4% |
5.2%
6.2 pts worse
|
5.1%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 16.3% · Q3 14.5% · Q4 11.8% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
74.6%
17.1 pts better
|
81.7%
10 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 93.0% · Q3 87.5% · Q4 90.7% · 4Q avg 91.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.4% |
11.7%
3.7 pts worse
|
12.0%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 13.4% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.2%
0.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.4% · Q3 1.3% · Q4 1.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.0% |
73.6%
11.4 pts better
|
79.7%
5.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.6% |
22.0%
0.6 pts worse
|
23.9%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.6% · Observed 19.0% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-12-09 · Fire 2021-12-09
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2020-02-27 · Fire 2020-02-27
19 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2021-12-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-02-18
F · Potential for more than minimal harm
2021-12-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-02-18
E · Potential for more than minimal harm
2021-12-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-05-27
E · Potential for more than minimal harm
2021-12-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-02-18
E · Potential for more than minimal harm
2021-12-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-02-18
D · Potential for more than minimal harm
2021-12-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-02-18
D · Potential for more than minimal harm
2021-12-09
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-02-18
D · Potential for more than minimal harm
2021-12-09
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-02-18
D · Potential for more than minimal harm
2021-12-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-02-18
E · Potential for more than minimal harm
2020-02-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-01-20
E · Potential for more than minimal harm
2020-02-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-01-20
E · Potential for more than minimal harm
2020-02-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-01-20
D · Potential for more than minimal harm
2020-02-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-01-20
D · Potential for more than minimal harm
2020-02-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-01-20
D · Potential for more than minimal harm
2020-02-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-01-20
D · Potential for more than minimal harm
2020-02-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-01-20
D · Potential for more than minimal harm
2020-02-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-01-20
C · Minimal harm
2020-02-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-01-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-01-07
D · Potential for more than minimal harm
2024-12-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-07
D · Potential for more than minimal harm
2024-12-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-07
D · Potential for more than minimal harm
2023-09-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-09-27
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-09-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-09-27
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-05-03
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-05-03
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-05-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-05-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-05-03
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-05-17
D · Potential for more than minimal harm
2021-12-09
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-12-29
D · Potential for more than minimal harm
2021-12-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-12-29
D · Potential for more than minimal harm
2021-12-09
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2021-12-29
D · Potential for more than minimal harm
2021-12-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-12-29
F · Potential for more than minimal harm
2020-02-27
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2020-04-03
E · Potential for more than minimal harm
2020-02-27
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2020-04-03
E · Potential for more than minimal harm
2020-02-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2020-04-03
E · Potential for more than minimal harm
2020-02-27
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2020-04-03
E · Potential for more than minimal harm
2020-02-27
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2020-04-03
E · Potential for more than minimal harm
2020-02-27
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2020-04-03
D · Potential for more than minimal harm
2020-02-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2020-04-03
D · Potential for more than minimal harm
2020-02-27
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2020-04-03
D · Potential for more than minimal harm
2020-02-27
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2020-04-03
D · Potential for more than minimal harm
2020-02-27
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2020-04-03
D · Potential for more than minimal harm
2020-02-27
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2020-04-03
D · Potential for more than minimal harm
2020-02-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-04-03
D · Potential for more than minimal harm
2020-02-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-04-03
D · Potential for more than minimal harm
2020-02-27
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-04-03
D · Potential for more than minimal harm
2020-02-27
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2020-04-03
Penalties and ownership
What sits behind the stars
Ownership
Knestout, Barry
5% Or Greater Direct Ownership Interest · Individual
Blum, Jonathan
Operational/Managerial Control · Individual
Blum, Jonathan
Corporate Director · Individual
Catrambone, Joseph
Operational/Managerial Control · Individual
Knestout, Barry
Operational/Managerial Control · Individual
Knestout, Barry
Corporate Director · Individual
Knestout, Barry
Corporate Officer · Individual
Kreck, Michael
Operational/Managerial Control · Individual
Kreck, Michael
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Shalom Gardens Health & Rehabilitation
Richmond, VA
4-star overall rating with 4-star inspections with $12,177 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Canterbury Rehabilitation And Healthcare Center
Richmond, VA
1-star overall rating with 1-star inspections with $92,980 in total fines with 40 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Lakewood Manor
Richmond, VA
3-star overall rating with 3-star inspections with 3 recent health deficiencies
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