VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Our Lady of Perpetual Help Health Center
4560 Princess Anne Road
Va beach, VA 23462
(757) 495-4211

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: March 9, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 BUILDING AND GROUNDS

Comments:

An unannounced monitoring inspection was conducted by the Licensing Inspector (LI) from the Eastern Regional Office on 03-09-2022 from 8:42 AM to 4:38 PM. There were 73 residents in care at the time of the inspection. LI reviewed 3 staff records, 4 resident records, emergency supply, and criminal background checks for all new staff since the last inspection. Water temperatures were sampled, breakfast meal observed, and conducted medication observations. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. The areas of noncompliance were discussed with the Administrator throughout the inspection and during the exit interview.

Violations:

Standard #:	22VAC40-73-260-C
Description:	Based on observation and interview, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR be posted in the facility so that the information is readily available to all staff at all times. Evidence: 1. Staff #1 confirmed and acknowledged a listing of all staff who have current certification in first aid or CPR is not posted in the facility.
Plan of Correction:	The Administrative Assistant posted a list of all staff who have current certification in First Aid and CPR. The Administrator or Administrative Assistant will perform ongoing monitoring to ensure the required posting remains in place.
Standard #:	22VAC40-73-350-B
Description:	Based on record review, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and failed to document that this was ascertained and the date the information was obtained. Evidence: 1. Resident #3 (admitted 11/16/21) did not have a sex offender screening documented in their resident record.
Plan of Correction:	A sex offender screening was completed by the Director of Admissions, on resident #3, with a clear result. The Administrator will perform an audit to ensure all other residents have had the pre-admission sex offender screenings completed and are in their files. The Administrator or designee will monitor for completion of sex offender screenings, prior to admission of new residents
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to ensure the interior and exterior of all buildings be maintained in good repair and kept clean and free of rubbish. Evidence: 1. During a tour of the facility on 03-09-2022, a shared shower room between the Lily and Rose units was observed. In one of the shower stalls with the whirlpool tub, a hole was noted on the wall. In the Rose unit, a ceiling tile was noted with a brown stain in Resident #10?s apartment.
Plan of Correction:	The hole noted in the shower room wall of the combined Lily / Rose Pavilion shower room, was repaired. The ceiling tile in resident # 10?s room (room R-6) was replaced. Daily rounds will be conducted by the Administrator or designee / Director of Maintenance or designee / Housekeeping Staff / Nursing Staff to monitor for the presence of areas of concern. Any noted areas will be referred to the appropriate department to be addressed.