Virginia DSS · Assisted Living Facility

Our Lady of Perpetual Help Health Center

📍 4560 Princess Anne Road, Va Beach, VA, 23462

ID 22203Three Year licenseActive
9
Inspections
On record
3
With violations
Visits that cited something
6
Clean visits
Nothing cited
17
Violations cited
Individual findings
15
Standards cited
Distinct rules
2
Complaint visits
Prompted by a complaint

Our Lady of Perpetual Help Health Center was inspected 9 times between April 7, 2021 and March 26, 2026 by the Virginia Department of Social Services. 3 of those visits ended with violations cited and 6 with none. Across that history VDSS cited 17 violations under 15 distinct standards. 2 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 8 of these 9 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Three Year
License expires
05/27/2029
Administrator
Teresa Anderson
Licensing inspector
Lanesha Allen
Inspector phone
757-715-1499
Approved for
Special Care Unit · Assisted Living · Non-Ambulatory

Inspection History

9

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

March 26, 2026Inspection0 violations
Inspection dates
03/26/2026
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Technical assistance
22VAC40-73-640.
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/26/2026 from 8:30 am until 3:05 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed:3 Number of interviews conducted with residents:4 Number of interviews conducted with staff: 8 Observations by licensing inspector: Breakfast, lunch and an activity was observed during this visit. A medication Pass, Call Bell check, First Aid kit and Emergency Preparedness was also observed during this onsite. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 18, 2025Complaint survey0 violations
Inspection dates
06/18/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/18/2025 1:40 pm to 2:40pm. Number of residents present at the facility at the beginning of the inspection: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed:0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Resident record review, review of hospice documentation and interview with staff occurred during this visit. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 29, 2025Inspection0 violations
Inspection dates
04/29/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
22VAC40-73-450 Individualized service plans
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/24/2025 11:00 am to 4:00pm. Number of residents present at the facility at the beginning of the inspection: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed:3 Number of interviews conducted with residents:2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Lunch, activity and medication pass were observed by licensing inspector. Tour of the facility interior/ exterior and first aid kits reviewed. Water Temperature checked. Additional Comments/Discussion: 22VAC40-73-450 Individualized service plans An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 27, 2024Inspection4 violations
Inspection dates
03/27/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
22VAC40-73-550
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/27/2024 from 8:40 am to 4:30 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 80 Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Breakfast and an activity were observed. A medication pass observation was completed for 4 residents. The following were reviewed: resident and staff records, medication carts, and water temperatures. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-680-D
Based on record review, the facility failed to ensure medication be administered in accordance with the physician's or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident #6 has an order to administer Muro-128 5% ointment 2 times daily to the left eye. Resident #6’s March MAR shows the AM dose was changed from 6 am to 9 am on 03/20/2024; however, the 6 am dose was never discontinued.
  2. The March MAR for Resident #6 shows the resident has received the ointment 3 times daily since 03/20/2024.
Plan of correction
1) The medication administration time for resident #6’s Muro-128 5% was clarified and corrected by the Unit Coordinator, on 3/27/2024. 2) Each unit coordinator will perform an audit to review the Physician Orders against the Medication Administration Records (MAR) to assess for accuracy in the orders and on the MAR. 3) The 11-7 nurse, will check physician orders, against the MAR for completion and accuracy, nightly. The Unit Coordinator will perform an audit of Physician orders against the MAR to ensure compliance with accuracy is achieved. Audits will occur weekly x4, then monthly x3. 4) The Director of Nursing, or designee, will review the audits and submit to the QA committee, for their review.
22VAC40-73-260-A
Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.
Evidence
  1. Staff #2 works as direct care staff and does not have a current certification in first aid.
Plan of correction
1) Staff #2 is scheduled to take First Aid training on 4/12/2024. 2) An audit of the direct care staff members files will be performed to assess for current First Aid certification. Those not in compliance will be scheduled for the next available class. 3) The community will schedule First Aid training courses, monthly as employees are coming due for recertification. 4) The Director of Nursing, or designee, will review the direct care staff member list, monthly, to determine who is due for their First Aid renewal course and have them scheduled, accordingly.
22VAC40-73-640-A
Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication.
Evidence
  1. The following expired medications were observed in the medication carts at the facility: PRN Docusate Sodium 100 mg capsules expired 02/29/2024 for Resident #9, 2 cards of Quetiapine Fumarate 25 mg tablets both expired 11/30/2023 for Resident #10, and PRN Ondansetron 4mg tablets expired 11/30/2023 for Resident #11.
Plan of correction
1) The expired medications for residents #9, #10 and #11 were removed from the carts and were properly destroyed on 3/27/2024. 2) All medications carts have been audited to ensure there were no other expired medications. 3) Medication cart audits will be performed weekly x4, then monthly x3 to ensure there are no expired medications on the carts. The cart audits will be performed by a peer or manager. 4) The Director of Nursing, or designee, will monitor audit results and present to the QA committee for review.
22VAC40-73-450-E
Based on record review, the facility failed to ensure the individualized service plan be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative when reviews and updates of the plan have been made.
Evidence
  1. The ISPs for Resident #5 (updated 3/22/2024) and Resident #6 (updated 03/07/2024) were both updated; however, they were not signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative.
Plan of correction
1) The Individualized Service Plans (ISP’s) for residents #5 and #6 have been signed and dated, by the team member completing the update and have been reviewed with the resident’s RP. The RP’s have been requested to sign-off on these updates, upon their next visit to the community. 2) An audit will be performed, by the Unit Coordinators to ensure each resident’s ISP has the appropriate signatures and dates for any updates that have been performed. 3) The Unit Coordinator will perform audits to ensure updates have appropriate signatures and dates. The audits will occur weekly x4, then monthly x3. 4) The Director of Nursing, or designee, will review the audits and submit to the QA committee, for their review.
June 14, 2023Inspection0 violations
Inspection dates
06/14/2023
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/14/2023 from 11:55 am to 12:05 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 06/12/2023 regarding allegations in the area(s) of: Building and Grounds. Observations by licensing inspector: LI walked throughout memory care units to include apartments at random within each unit. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 28, 2023Inspection10 violations
Inspection dates
03/28/2023, 03/30/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
22VAC40-73-290
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/28/2023 from 8:30 am to 4:45 pm and 03/30/2023 from 8:25 am to 11:15 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 75 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-940-A
Based on record review, the facility failed to comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official.
Evidence
  1. The last inspection by the appropriate fire official was completed on 04/22/2021.
Plan of correction
1) The Annual Fire Inspection was completed by the Deputy Fire Marshal from the City of Va. Beach Fire Department on 3/31/2023. 2) The Maintenance Director will contact the city of Va. Beach Fire Marshal’s office, 2 months prior to the due date, to request the annual inspection be scheduled.
22VAC40-73-700-3
Based on record review, the facility failed to ensure that only oxygen from a portable source be used by residents when they are outside their rooms. The use of long plastic tether lines to the source of oxygen outside their rooms is not permitted.
Evidence
  1. During a tour of the facility, Resident #14 was noted in the common dining area with an oxygen concentrator with long plastic tether line.
  2. Staff #7 acknowledged Resident #14 did not have access to a portable source of oxygen to be used outside of their room.
Plan of correction
1) The order was obtained and the necessary testing has been performed on resident #14, to allow for the ability to receive portable tanks for her usage. Delivery of a portable oxygen source has occurred. 2) An audit of all residents receiving oxygen will occur to ensure each resident has a portable source of oxygen available, when out of their rooms. 3) The Unit Coordinators will review the list of residents receiving oxygen, monthly x2, then quarterly, for the next 2 quarters, to ensure a portable source of oxygen is available. 4) The DRS / DON will review the audit results and submit to the QA committee, for their review.
22VAC40-73-325-B
Based on record review, the facility failed to ensure a fall risk rating is completed at least annually, when the condition of the resident changes, and after a fall.
Evidence
  1. Upon review of the resident’s record, the last annual fall risk rating for Resident #1 was completed on 09/23/2021.
Plan of correction
1) The annual fall risk assessment was completed for resident #1 on 3/28/2023 2) An audit will be performed, by the Unit Coordinators to ensure each resident has a fall risk assessment completed, on admission, after each fall and annually. 3) The Unit Coordinator will perform a quarterly audit of the fall risk assessments to ensure compliance is achieved. Audits will occur quarterly, for the next 3 quarters. 4) The Director of Resident Services will review the quarterly audits and submit to the QA committee, for their review.
22VAC40-73-440-L
Based on record review, the facility failed to maintain the completed UAI in the resident's record.
Evidence
  1. Resident #7’s UAI dated 2/9/2023 indicates the resident requires assistance with bowel and bladder incontinence; however, it does not indicate the type of assistance the resident needs. The UAI for Resident #7 also indicates the resident is disoriented to some spheres all of the time; however, it does not indicate the spheres the resident is disoriented to.
Plan of correction
1) The UAI on resident #7, dated 2/9/2023, was been completed to include the two missing items od documentation (bladder/ bowel incontinent assistance and orientation level) on 3/28/2023. 2) An audit will be performed, by the Unit Coordinators to ensure each resident’s UAI is complete and there are no missing items. – 3) The Unit Coordinator will perform a quarterly audit of the UAI’s to ensure compliance is achieved. Audits will occur quarterly, for the next 3 quarters. 4) The Director of Resident Services will review the quarterly audits and submit to the QA committee, for their review.
22VAC40-73-320-B
Based on record review, the facility failed to annually complete a risk assessment for tuberculosis on each resident as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. The last risk assessment for TB completed for Resident #6 and Resident #7 was 3/11/2022.
Plan of correction
1) The risk assessment for TB was completed for residents #6 and #7, on 3/28/2023 2) An audit will be performed, by the Unit Coordinators to ensure each resident has an annual TB assessment completed. 3) The Unit Coordinator will perform a quarterly audit of the risk assessments for TB to ensure compliance is achieved. Audits will occur quarterly, for the next 3 quarters. 4) The Director of Resident Services will review the quarterly audits and submit to the QA committee, for their review.
22VAC40-73-660-A-3
Based on observation, the facility failed to ensure the individual responsible for medication administration keep the keys to the storage area on their person.
Evidence
  1. During a tour of the facility, the medication cart was observed to be unattended with the keys noted on the cart and not on the individual responsible for medication administration.
Plan of correction
1) All Licensed nurses and Registered medication aides have been inserviced on community policies and protocols concerning ensuring keys being kept in the possession of the individual responsible for medication administration. 2) Audits will be performed by the DON / DRS to ensure the carts remain locked when not in active use and that keys are in the possession of the licensed nurse or registered medication aide. Audits will occur weekly x 4 weeks, then monthly x 2, then quarterly x 2. 3) Results of audits will be provided to the QA committee, quarterly, for review and determination of need for continuation.
22VAC40-73-640-A
Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication.
Evidence
  1. During a review of the medication cart with Staff #1, a bottle of Lisinopril 20 mg tablets for Resident #13 expired 09/30/2022 were observed on the medication cart.
Plan of correction
1) The expired medications for resident #13, that were contained in a bag, placed in the bottom of the medication cart for safe keeping until destruction could occur, have been removed and properly destroyed. 2) All medications carts have been audited to ensure there were no other expired medications. 3) Medication cart audits will be performed weekly x 4 weeks, then monthly ongoing to ensure there are no expired medications on the cart. 4) The Director of Resident Services and DON will monitor audit results and present to the QA committee for review.
22VAC40-73-680-D
Based on record review, the facility failed to ensure medication be administered in accordance with the physician's or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. The March MAR for Resident #2 does not indicate their 6am dose of Acetaminophen 500mg caplet was administered on 3/4/23, 3/7/23, 3/12/23, 3/18/23, 3/19/23, and 3/22/23. The March MAR for Resident #2 also does not indicate Anti-Fungal 1% Powder and Calmoseptine .44-20.6% Ointment was administered/applied on the night shift on 3/3/23, 3/6/23, 3/11/23, 3/12/23, 3/17/23, 3/20/23, 3/21/23, 3/22/23, and 3/25/23.
Plan of correction
1) For preventative, over-the-counter barrier creams that can be performed by direct care staff, the facility will have the documentation occur on the ADL sheets. Any nurse that does not have the ability to access the electronic medical record, will perform the documentation of the medication administration, on a paper record, to ensure appropriate documentation occurs. 2) The unit coordinator will review all Medication Administration Records (MAR’s) to assess for completion of documentation. 3) The Unit Coordinator will perform a monthly audit of the MAR’s to ensure compliance is achieved. Audits will occur monthly x2 then quarterly, for the next 2 quarters. 4) The DRS / DON will review the audits and submit to the QA committee, for their review.
22VAC40-73-210-G
Based on record review, the facility failed to ensure there is documentation of the type of training received, the entity that provided the training, number of hours of training, and dates of the training kept by the facility in a manner that allows for identification by individual staff person and is considered part of the staff member's record.
Evidence
  1. The records for Staff #3 and Staff #5 do not include documentation of the annual refresher course in medication administration for medication aides.
Plan of correction
1) Staff #5 is scheduled to take the annual refresher course on 4/13/2023. Staff #3 is no longer serving in a Registered Medication Aide capacity. 2) An audit of the Registered Medication Aide’s files will be performed to assess for the completion of the annual refresher course in medication administration for medication aides. Those not in compliance will be scheduled for the next available class. 3) Community educator will complete the training course, to be able to offer the refresher course, in-house, to our employees. 4) The Director of Resident Services will review the Registered Medication Aide list, monthly, to determine who is due for their annual refresher course and have them scheduled, accordingly.
22VAC40-73-325-A
Based on record review, the facility failed to ensure for residents who meet the criteria for assisted living care, by the time the comprehensive ISP is completed, a written fall risk rating be completed.
Evidence
  1. Upon review of the resident’s record, Resident #2 meets the criteria for assisted living care; however, there is no documentation of a fall risk rating being completed in the resident’s record.
Plan of correction
1) The fall risk assessment for resident #2 was completed on 3/28/2023. 2) An audit will be performed, by the Unit Coordinators to ensure each resident has a fall risk assessment completed, on admission, after each fall and annually. 3) The Unit Coordinator will perform a quarterly audit of the fall risk assessments to ensure compliance is achieved. Audits will occur quarterly, for the next 3 quarters. 4) The Director of Resident Services will review the quarterly audits and submit to the QA committee, for their review.
June 16, 2022Complaint survey0 violations
Inspection dates
06/16/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/16/2022 from 11:00am to 11:20am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/25/2022 regarding allegations in the area(s) of: Resident Care and Related Services and Building and Grounds. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 9, 2022Inspection3 violations
Inspection dates
03/09/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 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
22VAC40-73-350-B
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
22VAC40-73-870-A
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.
22VAC40-73-260-C
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.
April 7, 2021Inspection0 violations
Inspection dates
April 7, 2021 and April 8, 2021
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 4/7/21 and concluded on 4/8/21. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 71. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, staff schedules, fire and emergency drills, health care oversight, health inspection report and fire inspection report submitted by the facility to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.