Inspection Report
Renewal
Census: 11
Deficiencies: 0
May 29, 2025
Visit Reason
A state licensure survey was conducted to assess compliance with State Long Term Care requirements.
Findings
The survey team determined the facility was in substantial compliance with State Long Term Care requirements.
Inspection Report
Original Licensing
Census: 12
Deficiencies: 0
Apr 27, 2023
Visit Reason
A licensure survey was conducted by a qualified survey team from April 25, 2023 through April 27, 2023 to assess compliance for licensing purposes.
Findings
The facility was found to be in compliance and no deficiencies were cited during the licensure survey.
Inspection Report
Routine
Census: 13
Deficiencies: 0
Aug 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with federal regulations and recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 emergency preparedness requirements and 42 CFR §483.80 infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Inspection Report
Renewal
Deficiencies: 0
Feb 13, 2020
Visit Reason
Licensure survey conducted to determine compliance with State Long Term Care Requirements.
Findings
No deficiencies were cited during the licensure survey.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 21, 2019
Visit Reason
A desk revisit was conducted on March 21, 2019 to review citations from the Recertification survey on January 18, 2019.
Findings
All citations from the January 18, 2019 Recertification survey have been corrected.
Inspection Report
Annual Inspection
Census: 19
Deficiencies: 1
Jan 18, 2019
Visit Reason
The inspection was conducted as a licensure survey to determine compliance with State Long Term Care Requirements during the annual recertification survey.
Findings
The facility failed to ensure that background checks were completed for five of the ten employee files reviewed, including the Director of Nursing, Licensed Practical Nurse, Certified Nursing Assistants, and Activities Director. The Administrator confirmed that background checks were not found and that employees would need to have them redone.
Severity Breakdown
SS=0: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure background checks were completed on five of ten employee files reviewed during the annual recertification survey. | SS=0 |
Report Facts
Employees without background checks: 5
Total census: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Employee file lacked evidence of background check since hire date 10/8/18. |
| Licensed Practical Nurse AA | Licensed Practical Nurse | Employee file lacked evidence of background check since hire date 7/25/10. |
| Certified Nursing Assistant BB | Certified Nursing Assistant | Employee file lacked evidence of background check since hire date 10/20/15. |
| Activities Director | Activities Director | Employee file lacked evidence of background check since hire date 7/27/15. |
| Certified Nursing Assistant DD | Certified Nursing Assistant | Employee file lacked evidence of background check since hire date 1/15/12. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 23, 2017
Visit Reason
An unannounced complaint survey was conducted at Our Lady of Perpetual Help by a Registered Nurse Surveyor.
Findings
There were no deficiencies identified during the complaint survey.
Complaint Details
Unannounced complaint survey with no deficiencies identified.
Inspection Report
Renewal
Deficiencies: 0
Mar 14, 2017
Visit Reason
A re-licensure survey was conducted to assess the facility's compliance for license renewal.
Findings
The facility was found to be in compliance without any deficiencies during the re-licensure survey.
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