Virginia DSS · Assisted Living Facility

Harmony at Oakbrooke

📍 301 Clearfield Avenue, Chesapeake, VA, 23320

ID 44508Two Year licenseActive
16
Inspections
On record
10
With violations
Visits that cited something
6
Clean visits
Nothing cited
45
Violations cited
Individual findings
32
Standards cited
Distinct rules
9
Complaint visits
Prompted by a complaint

Harmony at Oakbrooke was inspected 16 times between November 6, 2020 and December 29, 2025 by the Virginia Department of Social Services. 10 of those visits ended with violations cited and 6 with none. Across that history VDSS cited 45 violations under 32 distinct standards. 9 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. 13 of these 16 are still on the state's site; the other 3 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
12/27/2027
Administrator
Jennifer Stell
Licensing inspector
Alyshia Walker
Inspector phone
(757) 670-0504
Approved for
Assisted Living

Inspection History

16

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

December 29, 2025Inspection4 violations
Inspection dates
12/29/2025
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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 SUBJECTIVITY22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
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: 12/29/2025 8:30 am- 4:25 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: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes.
Evidence
  1. A review of the Controlled Substances/Inventory Log for the months of November 2025 and December 2025 documented staff failed to ensure counts of all controlled substances occurred between oncoming staff and off going staff for medication carts in the memory care and assisted living units.
  2. Staff #3 acknowledged the Change of Shift-Controlled Medication Count Sheet was not completed for each change of shift.
Plan of correction
HCD, HSD, ED or designee will audit narcotic inventory logs on a weekly basis to ensure compliance with the medication management plan. RMAs will be re-educated on the medication management plan as it pertains to the oncoming/offgoing narcotic inventory logs.
22VAC40-73-940-A
Based on the record review the facility failed to ensure an assisted living facility shall 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 facility's last recorded annual fire inspection was 11/6/2024.
  2. Staff #7 acknowledged the facility's last annual fire inspection was 11/6/2024.
Plan of correction
Fire Marshall inspected community on 11/25/2025. Going forward, Executive Director or Maintenance Director will request an inspection at least two months prior to annual inspection expiration.
22VAC40-73-210-B
Based on the on-site record review and staff interview the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually. (Exception: Direct care staff who are licensed health care professions or certified nurse aides shall attend at least 12 hours of annual training).
Evidence
  1. During the review of staff records, the record for Staff # 1 (date of hire 12/6/2021) did not contain documentation of the required number of training hours for a direct care staff.
  2. Staff #7 acknowledged the staff training records for Staff # 1 were not available for the inspector to review.
Plan of correction
The learning management system was inaccessible during inspection. ED or BOM will print staff learning transcripts twice a year or before a known outage to ensure staff records are up to date with required CEUs. ED or BOM will audit learning compliance monthly to ensure staff are completing their learning modules.
22VAC40-73-325-B
Based on the record reviewed, the facility failed to ensure that a fall risk assessment was reviewed and updated after a resident experience a fall.
Evidence
  1. Resident #6 had documented falls on 11/1/2024 and 11/27/2024. There were no fall risk assessments for the associated falls.
  2. Staff # 5 and Staff # 6 acknowledged there were no fall risk assessments for the falls.
Plan of correction
HCD and HSD will ensure a fall risk assessment is completed after each fall. HCD, ED, or HSD will audit fall reports weekly to ensure fall assessments are completed and interventions initiated in the EMR.
July 1, 2025Inspection0 violations
Inspection dates
07/01/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 7/1/2025 10:15 am- 11:10 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: 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: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing Inspector inspected training for RMAs, inspected medication carts on both the memory care and assisted living units, the facility’s self-monitoring tools regarding medication administration, medication refills, and management of narcotic inventory. 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 1, 2025Complaint survey0 violations
Inspection dates
07/01/2025
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: 7/1/2025 11:15 am- 11:45 am 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 2/28/2025 regarding allegations in the area(s) of: Resident Care and Related Services and Buildings and Grounds 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: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 13, 2025Inspection4 violations
Inspection dates
01/13/2025, 1/30/2025
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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
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: 1/13/2025 (9:06 am- 1:52 pm), 1/30/2025 10:40 am- 12:40 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: 78 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on resident record review, the facility failed to follow their medication management plan in regard to ensuring each resident’s prescription medication and any over the counter drugs for the resident are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. The medication administration record for January 2025, for Resident # 5 notated the resident’s Buspirone 10 mg was not available to be administered on 1/6/2025 (am dose), 1/12/2025 (am and pm doses), and 1/13/2025 (am dose).
Plan of correction
Medication Management Plan will be reviewed with each RMA as it pertains to medication availability and ordering. HSD and HCD will conduct cart audits on an ongoing basis to ensure medications are available for administration.
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all of the required elements listed in 22VAC-43-450-C.
Evidence
  1. The ISP for Resident # 1 dated 7/1/2024, did not include outcome dates for the identified needs listed.
Plan of correction
HCD, HSD, and ED will ensure all ISP goals have an outcome date. After current ISPs are corrected, ED will audit each ISP going forward to ensure compliance.
22VAC40-73-640-A
Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes.
Evidence
  1. A review of the Narcotic Inventory Count Verification forms for the months of November 2024, December 2024 and January 2025 documented staff failed to ensure counts of all controlled substances occurred between oncoming staff and off going staff.
Plan of correction
Medication Management Plan will be reviewed with each RMA as it pertains to Narcotic counts. HSD and HCD will audit on a weekly basis to ensure compliance with the standard.
22VAC40-73-680-C
Based on record review, the facility failed to ensure medications be administered no earlier than one hour before and no later than one hour after the facility’s standard dosing schedule, except for those drugs that are ordered for specific times.
Evidence
  1. A review of the Medication Administration Audit Report for January 1, 2025, through January 13, 2025, for residents #3, #4, and #5 documented the residents received medication late on 1/1/2025, 1/11/2025, and 1/13/2025.
Plan of correction
Medication Management Plan will be reviewed with each RMA as it pertains to timeframes of administration of medications. HSD and HCD will conduct a bi-weekly random audit of the administration reports to ensure compliance.
January 13, 2025Complaint survey0 violations
Inspection dates
01/13/2025, 01/30/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 1/13/2025 (9:06 am – 1:52 pm) and 1/ 30/2025 (10:40 am- 12:40 pm) 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 12/5/2024 regarding allegations in the area(s) of: Staffing Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 78 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Additional Comments/Discussion: 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 13, 2025Complaint survey0 violations
Inspection dates
01/13/2025, 01/30/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 1/13/2025 (9:06 am – 1:52 pm) and 1/ 30/2025 (10:40 am- 12:40 pm) 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 12/5/2024 regarding allegations in the area(s) of: Staffing Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 78 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Additional Comments/Discussion: 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 19, 2024Complaint survey1 violation
Inspection dates
07/19/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 7/19/2024 9:30 am – 1:30 pm 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 6/11/2024regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on a review of facility records, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. Licensing Inspector received a complaint from a family member regarding medication not being administered to Resident #1 as prescribed by the physician. The family member sent pictures of unadministered medication they received back from the staff at the end of the month. The family member confirmed the resident had been at the facility every day for the time period the medications should have been administered. The pictures submitted to the Licensing Inspector documented the following medications and number of pills remaining on the medication cards: Leflunomide 10 mg (prescribed-1 pill to be administered in the morning for RA) 5 pills on the morning medication card which originally contained 31 pills Preservision (prescribed for eye health) 4 pills remaining on the morning medication card which originally contained 31 pills Vitamin D3 (prescribed as a supplement) 4 pills remaining on the morning medication card which originally contained 31 pills Metoprolol Succ ER 50 mg (prescribed for blood pressure) 4 pills remaining on the morning medication card which originally contained had 31 pills Olmesartan Medoxomil 40 mg (prescribed for high blood pressure) 14 pills remaining on the morning medication card which originally contained had 31 pills Clopidogrel 75 mg (prescribed for transient ischemic attack -TIA) 6 pills remaining on the medication card which had 31 pills which originally contained had 31 pills Citalopram 10 mg (prescribed for mood) 7 pills remaining on the medication card which originally contained had 31 pills Creon DR 36,000 units (prescribed for IBS) 12 pills remaining on the medication card which had 31 pills
  2. On 7/19/2024, during the on-site inspection, the Licensing Inspection conducted an inspection of the medication cart. The Licensing Inspector reviewed the following medications and pills remaining in the medication cards: Colestipol HCL 1GM- (prescribed for IBS) there were 5 pills remaining on the card which originally contained had 31 pills Colestipol HCL 1GM- (prescribed for IBS) there were 8 pills remaining on the card which originally contained 30 pills Divaloprex 250 mg- (prescribed for mood stabilization)- there were 10 pills remaining on the card which originally contained 30 pills
  3. The Licensing Inspector reviewed the Medication Administration Record for the month July 2024. There were only documented 3 days the resident either refused or was unavailable to take medication.
  4. The Pharmacy Review provided to the Licensing Inspector for July 2024, did not have Resident # 1 listed as frequently refusing medications.
  5. The Licensing Inspection interviewed the Harmony Square Director regarding the inconsistencies in the medication count on the medication cards. The Harmony Square Director was unable to explain why the pills administered on the medication cards did not coincide with the days of the month. The Harmony Square Director could not explain in what order the Registered Medication Aides were administering the medication from the medication cards as there were two medications that were to be administered at the same time of day however they were not administered from the same date on both medication cards. Furthermore, the Harmony Square Director could not tell the Licensing Inspector on what date the medication was delivered from the pharmacy.
  6. Licensing Inspector contacted the pharmacy which verified Resident #1’s medication is sent to the pharmacy, the pharmacy repackages the medication, and the pharmacy sends the medication to the facility in a 30-day supply. The number of pills documented remaining in the medication packages are outside of norm.
Plan of correction
HSD or HCD will audit medications on an ongoing basis to ensure medications are being administered. HSD or HCD will also perform cart audits, MAR audits, and administration records to ensure compliance. HSD or HCD will ensure repackaged medication receipts are kept in the residents record as not all medications that are repackaged are sent and received at the same time.
May 30, 2024Inspection8 violations
Inspection dates
05/30/2024
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 REPORT22VAC40-80 THE LICENSE
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: 5/30/2024 8:10 am- 2:30 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: 60 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Licensing inspector observed activities being conducted, a meal, and medication passes. 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 Alyshia E. Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-40-B
Based on staff record review, the facility failed to obtain the criminal history record report on or prior to the 30th day of employment for an employee.
Evidence
  1. During the inspection conducted on 5/30/224, a record review indicated the date of hire for Staff #4 was 12/19/2023. The staff’s record did not contain a completed criminal history record report.
  2. Staff #1 acknowledged the record did not contain a criminal history record report.
Plan of correction
ED and BOM will utilize the new hire checklist to ensure all new hires have a submitted criminal background request prior to the employee starting. The staff member who did not have a criminal background check on file has one on file now and remains employed at the community.
22VAC40-73-430-H-1
Based on review of resident record, the facility failed to ensure that a discharge statement included all the required information listed in the standards to be provided to the resident and as appropriate, his legal representative and designated contact person at the time of discharge.
Evidence
  1. The file for Resident #1 did not contain a discharge statement.
  2. Staff #1 acknowledged the file did not contain a discharge statement.
Plan of correction
ED and BOM will ensure each resident has a discharge statement completed upon move out.
22VAC40-73-290-B
Based on observation, the facility failed to ensure the posting of the name of the current on-site person in charge.
Evidence
  1. On the date of the inspection 5/30/2024, the posting of the on-site person in charge was not accurately updated to reflect the person who was in charge of the building at the time the inspector entered the building.
Plan of correction
ED updated the posting for the on-site person in charge. ED will ensure the posting remains accurate and is visible at the front desk.
22VAC40-73-450-F
Based on a review of resident records the facility failed to ensure that each resident's individualized service plan (ISP) contained a description of all needs/services identified.
Evidence
  1. Resident #3’s UAI dated 5/3/2024 stated the resident needed mechanical and supervision assistance in bathing. The resident’s ISP dated 5/3/2024 stated the resident only required mechanical assistance to complete bathing.
  2. Resident #3’s UAI dated 5/3/2024 stated the resident was disoriented some spheres, some of the time. The resident’s ISP dated 5/3/2024 stated the resident was oriented to all spheres.
  3. Resident #6’s UAI dated 5/1/2024 stated the resident did not need assistance in eating. The resident’s ISP dated 5/1/2024 stated the resident needed supervision in eating. The resident’s UAI stated the resident did not perform stairclimbing. The resident’s ISP stated the resident required mechanical and physical assistance in the area of stairclimbing.
  4. Resident #5’s UAI dated 3/22/2024 stated the resident only required mechanical assistance in walking. The ISP dated 3/22/2024 stated the resident required mechanical and supervision assistance in walking.
Plan of correction
HCD and HSD will ensure assessed needs on the UAI are accurately reflected on the ISP. ED will audit each UAI and ISP to ensure assessed needs are accurately reflected as well.
22VAC40-73-640-A
Based on record review, the facility failed to implement its written plan for medication management, specifically regarding methods to ensure that each resident’s prescription medications and over-the counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. The facility’s Medication Management Plan states that, “Nurses and RMA’s shall be responsible for the timely ordering, and re-ordering of medications so that there are no missed doses or interruptions in the medications being administered.” The policy further states, “If a medication is not available to administer for any reason, the nurse/RMA will contact the physician to inform of when the medication will be made available and seek further instruction. The physician’s instructions will be documented on the (E) MAR.”
  2. A review of the May 2024 MAR for Resident #3 documented the resident’s Symbicort Inhaler was not available to be administered on 5/3/2024, 5/6/2024, 5/8/2024, 5/10/2024, 5/12/2024. The resident’s Lidocaine 4% pain patch was not available to be administered on 5/14/2024. The resident’s Furosemide 20 mg was not available to be administered on 5/29/2024. The Metoprolol tartrate 25 was not available to be administered on 5/29/2024 and the Venlafaxine HCL 75mg was not available to be administered on 5/29/2024.
  3. A review of the May 2024 MAR for Resident #10 documented the resident’s Alprazolam 0.25 mg table was not available to be administered on 5/3/2024, 5/4/2024, 5/5/2024, 5/6/2024, 5/7/2024, 5/8/2024,5/9/2024, 5/24/2024, 5/25/2024, 5/26/2024, and 5/27/2024. The resident’s tramadol 50 mg was not available to be administered on 5/8/2024, 5/8/2024 and 5/9/2024.
Plan of correction
4 HCD and HSD or designee will audit medication availability twice per week. RMAs will be retrained on their responsibilities regarding ordering of medication in a timely manner, notifying a supervisor if there is an issue with obtaining a medication, and notifying the physician if a medication becomes unavailable.
22VAC40-73-640-A
Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes.
Evidence
  1. A review of the Controlled Medication Count Record for the medication carts on the 2nd and 3rd floors for the month of May 2024 documented staff failed to ensure counts of all controlled substances were documented on 31 out of 31 days reviewed.
  2. Staff members 2,3, and 5 all acknowledged the Controlled Medication Count Records were incomplete.
Plan of correction
ED, HCD, and HSD will audit narcotic inventory count sheets on a daily basis. RMAs will be retrained on their responsibility to accurately count and sign off on narcotic inventory sheets.
22VAC40-80-120-E-2
Based on observation, the center failed to post the findings of the most recent inspection of the facility.
Evidence
  1. During an inspection of the center on 5/30/2024, the findings of the most recent inspection of the center were not observed to be posted.
Plan of correction
ED will ensure that the DSS Inspection binder is readily available and within sight for anyone who wants to review them. The binder is kept on the counter at the front desk.
22VAC40-73-260-A
Based on a review of staff records the facility failed to ensure that each direct care staff member who did not have current certification in first aid shall receive certification in first aid within 60 days of employment.
Evidence
  1. The employee file for Staff #4 (D.O.H) 12/19/2023 did not contain evidence of the staff member having First Aid certification.
Plan of correction
ED and BOM will ensure all direct care staff obtain their First Aide and CPR within 60 days of their start date. ED and BOM will utilize the new hire checklist. Current staff who do not have their FA/CPR will attend a class within the next 2 months.
April 27, 2023Inspection15 violations
Inspection dates
04/27/2023, 05/05/2023
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
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: 4/27/2023 and 5/5/2023 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: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed:6 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 6 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 Alyshia E. Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-260-A
Based on a review of staff records the facility failed to ensure that each direct care staff member shall maintain current certification in first aid.
Evidence
  1. Staff #5’s file did not contain documentation the staff member completed First Aid.
  2. Staff #3’s file contained documentation the staff member’s First Aid expired on 9/1/2022.
Plan of correction
All direct care staff will have current CPR/First Aid. A tickler has been created to ensure compliance with the standard.
22VAC40-73-640-A
Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes.
Evidence
  1. The facility Medication Management Plan states, “Narcotics and other controlled substances will be counted shift to shift between the on-coming and off-going medication staff. Direct staff to staff hand off of the keys to the medication carts will take place after a correct inventory has been documented.
  2. A review of the Controlled Medication Count Record for the medication cart in the safe, secure unit for the month of April 2023, showed staff failed to ensure counts of all control medications were documented on 22 out of 27 days reviewed.
Plan of correction
All staff that are responsible for administering medications have been trained on the narcotic count procedures. HCD and MCD will ensure compliance with the standard.
22VAC40-73-650-A
Based on a review of resident records the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber.
Evidence
  1. The May 2023 Medication Administration Record (MAR) for Resident #6 shows the resident is currently receiving Aspirin 81 mg, Atorvastatin 10 mg, Calcium 600+, Clonidine HCL 0.1mg, Donepezil HCL 5mg, multivitamin tablet, and Sertraline HCL 25 mg tablet. There were no signed physician’s orders available for the inspector to review at the time of inspection.
  2. Staff #2 acknowledged there was no signed physician’s order in the resident file for the licensing inspector to review at the time of inspection.
Plan of correction
All medications, diet changes, or other orders will have a signed physician order on file. HCD or MCD will ensure any changes to medications, diets, etc. will have a signed physician order on file before a change is made.
22VAC40-73-1070-A
Based on observation, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident with a serious cognitive impairment, these materials or objects shall be in accessible to the resident except under staff supervision.
Evidence
  1. During the on-site inspection of the safe, secure unit, the kitchen door was propped open and there was liquid lavender pot and pan detergent in resident reach.
  2. Staff #1 acknowledged the door was open and the detergent was within resident reach.
Plan of correction
All directors and staff will ensure this door is shut and inaccessible.
22VAC40-73-1090-A
Based on record review, the facility failed to ensure prior to admission to a safe, secure environment, residents are assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Evidence
  1. Resident #3 was admitted to the facility on 3/14/23 and is in the safe, secure unit. The resident’s record did not contain an assessment by a clinical psychologist or independent physician which states the resident has a serious cognitive impairment due to dementia and has an inability to recognize danger or protect their safety and welfare.
Plan of correction
All SCU residents will have an assessment of serious cognitive impairment completed by their physician prior to admission into SCU.
22VAC40-73-450-C
Based on record review and interview with staff, the facility failed to ensure the comprehensive individualized service plan (ISP) completed within 30 days after admission.
Evidence
  1. Resident #3’s date of admission was 3/14/2023 and Resident # 5’s date of admission was 12/12/2022. There were no comprehensive ISPs in the residents’ records for the licensing inspectors to review at the time of inspection.
  2. Staff #2 acknowledged there was no comprehensive ISPs for inspectors to review at the time of the inspection.
Plan of correction
All residents will have a comprehensive ISP in place no more than 30 days after admission. HCD and MCD will ensure compliance with the standard.
22VAC40-73-320-B
Based on the review of facility records with the facility Administrator the facility failed to ensure that a risk assessment for tuberculosis was completed annually on each resident.
Evidence
  1. Resident # 4’s date of admission was 3/6/2020. The last documented TB evaluation in the resident’s record was dated 3/1/2022.
  2. Resident #7’s date of admission was 10/29/2021. The last documented TB assessment in the resident’s record at the time of the inspection was dated 10/22/2021.
Plan of correction
Not published by VDSS.
22VAC40-73-460-H
Based on the review of facility records and interviews conducted the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with bathing - at least twice a week, but more often if needed or desired.
Evidence
  1. There were no documented showers in the facility’s shower logs for residents in the safe, secure, unit for the month of April 2023.
  2. Staff #1 acknowledged the shower logs were not completed per the facility’s standards.
Plan of correction
Shower logs are in place and care staff are aware of their duty to document. HCD and MCD will ensure compliance of the standard.
22VAC40-73-450-E
Based on resident records review and staff interview, the facility failed to ensure the individualized service plans (ISP) were updated annually or as needed for a significant change of a resident’s condition.
Evidence
  1. Resident #4‘s ISP was last reviewed on 3/6/2021.
Plan of correction
UAIs and ISPs will be updated upon significant change in resident needs. HCD or MCD will ensure compliance with the standard.
22VAC40-73-250-C
Based on a review of staff records, the facility failed to verify that each staff person has received a copy of his or her current job description.
Evidence
  1. Staff #1’s file did not contain documentation of a signed job description. The signature line was blank.
Plan of correction
All staff will sign their job descriptions upon hire and will be maintained in their personnel file. BOM will ensure compliance with the standard.
22VAC40-73-310-H
Based on record reviewed and staff interviewed, the facility failed to ensure in accordance with 63.2-1805 D Code of Virginia, it did not admit or retain individuals with any prohibitive conditions without required documentation.
Evidence
  1. Resident # 4 has physician’s orders for Ativan and Haloperidol and there were no psychotropic treatment plans in the resident record at the time of inspection.
Plan of correction
All psychotropic medications will have a treatment plan on record completed by the physician. HCD or MCD will ensure compliance with the standard.
22VAC40-73-440-A
Based on review of resident record, the facility failed to ensure that uniform assessment instruments (UAIs) are completed as annually and as required.
Evidence
  1. Resident #4’s last documented UAI was dated 3/6/2021.
  2. Resident #6’s last documented UAI was dated 9/6/2021.
  3. Resident #5’s file did not contain a UAI for the inspector to review at the time of inspection.
Plan of correction
All resident UAIs and ISPs are current. A tickler is in place to ensure compliance. HCD or MCD will ensure UAIs and ISPs are updated at least annually or as needed.
22VAC40-73-610-B
Based on observations made during the tour of the facility on 4/27/2023, the facility failed to have the menu for the current week posted.
Evidence
  1. During the on-site inspection on 4/27/23, the daily posted menus for breakfast and lunch were dated for 4/26/23. There was no weekly menu posted.
Plan of correction
Weekly and daily menus are posted in conspicuous and visible locations. Dining Services Director or designee will ensure menus are posted per the standard.
22VAC40-73-290-B
Based on observation, the facility failed to ensure the posting of the name of the current on-site person in charge.
Evidence
  1. During the on-site inspection on 4/27/2023 there was no posting of the current on-site person in charge.
Plan of correction
Manager on Duty posting is at the front desk and visible at all times. ED will ensure compliance with the standard.
22VAC40-73-320-A
Based on record reviewed and staff interviewed, the facility failed to ensure within 30 days preceding admission, a person shall have a physical examination by an independent physician which includes the results of a risk assessment documenting the absence of tuberculosis in a communicable form 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: Resident # 3’s date of admission was 3/14/23. There was no initial physical or TB assessment in the resident file for licensing inspectors to review at the time of inspection.
Plan of correction
All residents will have a TB screening completed no more than 30 days prior to admission. HCD, MCD, or Marketing Director will ensure compliance with the standard.
April 27, 2023Complaint survey1 violation
Inspection dates
04/27/2023
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-80 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: 4/27/2023 8:38 am- 4:11 pm 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 4/24/2023 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed:0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaints but identified during the course of the investigation can also be found on the violation notice. 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 Alyshia E. Walker, Licensing Inspector at (757)670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on record review, the facility failed to implement its written plan for medication management, specifically regarding methods to ensure that each resident’s prescription medications and over-the counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. The facility’s Medication Management Plan states that, “Nurses and RMA’s shall be responsible for the timely ordering, and re-ordering of medications so that there are no missed doses or interruptions in the medications being administered. “ The policy further states, “If a medication is not available to administer for any reason, the nurse/RMA will contact the physician to inform of when the medication will be made available and seek further instruction. The physician’s instructions will be documented on the (E) MAR.”
  2. Resident #1 has a physician’s order for their blood sugar to be checked four times a day. The April 2023 Medical Administration Record for the resident states the resident’s blood sugar is to be checked at 6:00 am, 12:00 pm, 5:00 pm and 8:00 pm. The MAR documented the resident’s blood sugar was not checked 29 times due to blood sugar supplies not being unavailable
  3. Staff members #1 and #2 acknowledged the facility’s medication Management Plan was not followed.
Plan of correction
Staff responsible have been trained on procedures when medications or supplies are getting low to ensure the resident has what they need. HCD and MCD will monitor par levels for medications and supplies.
March 1, 2023Complaint survey4 violations
Inspection dates
03/01/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 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: 8:05am-12:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint # 56897 was received by VDSS Division of Licensing on 1/5/2023 regarding allegations in the area(s) of: Personnel Buildings and Grounds Activities Number of residents present at the facility at the beginning of the inspection: 27 Memory Care The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Licensing Inspector was unable to gain immediate access into the building upon arrival. LI waited approximately 10 minutes with a home health worker who had been waiting before LI arrived. Home health worker states she had waited 30 minutes for someone to come to open the door. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-870-B
Based on observations made during the tour of the physical plant, the facility failed to have the building well ventilated and free from foul, stale, and musty odors.
Evidence
  1. On 3/1/2023 during the onsite inspection, Licensing Inspector detected the strong smell of urine throughout the secure unit. Licensing Inspector toured resident rooms and detected the smell of urine.
  2. Staff members #1, #2, #3, and #4 acknowledged the safe secure unit had a strong odor of urine.
Plan of correction
Not published by VDSS.
22VAC40-73-870-A
Based on observation, the facility failed to ensure the interior and exterior of the building shall be maintained in good repair.
Evidence
  1. During the tour of the safe secure unit, the Licensing Inspector observed dark stains on the carpet in the hallways of the safe and secure unit. The inspector also observed several cloth chairs in the entrance hallway which were stained.
  2. Staff members #1, #2, #3, and #4 acknowledged the hallway carpet and furniture were stained.
Plan of correction
Not published by VDSS.
22VAC40-73-150-B
Based on communications with former staff, it was determined that the facility failed to immediately employ a new administrator or appoint a qualified acting administrator so that no lapse in administrator coverage occurs.
Evidence
  1. The Department received information that the facility’s administrator was no longer employed by the facility effective 2/9/2023. As of the date of this violation notice, the department has received no documentation or communication from the licensee of the employment of a new administrator or appointment of a qualified acting administrator.
Plan of correction
Not published by VDSS.
22VAC40-73-290-B
Based on observation and interview made during the tour of the building, the facility failed to implement a procedure for posting the name of the current on-site person in charge in a place that is conspicuous to the resident and the public.
Evidence
  1. A posting of the on-site person in charge was not observed during the inspection.
Plan of correction
Not published by VDSS.
March 1, 2023Complaint survey6 violations
Inspection dates
03/01/2023
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 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: 8:05am-12:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Several complaints # 568987 & 568900 were received by VDSS Division of Licensing on 1/5/2023, 1/23/2023, and 2/20/2023 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 27 Memory Care The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. 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 S hould you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-580-D
Based on record reviewed the facility failed to ensure when a resident UAI has been assessed as dependent in eating/feeding, the individualized service plan (ISP) shall indicate an approximate amount of time needed for meals to ensure needs are met.
Evidence
  1. Resident # 3 has a UAI (dated 1/1/23) which assessed the resident as being spoon fed by others. The ISP (dated 1/1/23) for Resident #3 does not indicate the approximate amount of time needed for meals.
Plan of correction
Not published by VDSS.
22VAC40-73-930-D
Based on family interviews and documentation reviewed, the facility failed to ensure the two hour documented rounds in memory care were being conducted and included the time of the rounds.
Evidence
  1. Documentation provided by the facility indicated rounds were conducted for each resident in the memory care unit at the exact same time.
Plan of correction
Not published by VDSS.
22VAC40-73-440-B
Based on record reviewed, the facility failed to ensure that uniform assessment instrument (UAI) forms were approved and signed by the administrator or the administrator's designee.
Evidence
  1. The UAI dated 1/1/2023 for Resident #3 did not contain an assessor signature or signature of the administrator or administrator designee.
Plan of correction
Not published by VDSS.
22VAC40-73-1130-C
Based on documentation reviewed, the facility failed to ensure that during night hours, when 23 to 32 residents are present, at least three direct care staff members shall be awake and on duty at all times in each special care unit.
Evidence
  1. The staffing sheet provided to the Licensing Inspector for 2/27/23 showed three staff members scheduled to work the overnight shift. There were two call outs and there was one substitution. This resulted in the unit having two staff members during the shift for the safe secure unit with 24 residents present.
Plan of correction
Not published by VDSS.
22VAC40-73-680-C
Based on records reviewed, the facility failed to ensure medication be administered not earlier than one hour before and not later than one hour after the facility’s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. A review of the December 2022 Medication Administration Record (MAR) for Resident #4 documented the resident received medications late 26 out of 31 days. A review of the January 2023 MAR documented the resident received medications late 11 out of 12 days reviewed.
  2. A review of the December 2022 MAR for Resident #5 documented the resident received medications late 16 out of 31 days. A review of the January 2023 MAR documented the resident received medications late 6 out of 6 days reviewed.
  3. A review of the December 2022 MAR for Resident #6 documented the resident received medications late 27 out of 31 days. A review of the January 2023 MAR documented the resident received medications late 12 out of 12 days reviewed.
Plan of correction
Not published by VDSS.
22VAC40-73-450-E
Based on resident record reviewed, the facility failed to have the Individualized Service Plan (ISP) signed by the resident or his/her legal representative.
Evidence
  1. The ISP dated 1/1/2023 for Resident #3 did not contain a resident or legal representative signature.
Plan of correction
Not published by VDSS.
December 16, 2021Inspection0 violations
Inspection dates
12/16/2021
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 ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
An unannounced renewal inspection was conducted on 12/16/21 (arrival 10:30 am/dep 6:00 pm) by two Licensing Inspectors. The facility census was 90. A tour of the facility was conducted, required posting were observed, am/pm snack and lunch menu posted, building temperature observed, records were reviewed, activities and medication passes were observed. Staff and resident files were reviewed, as well as fire drills and fire and health inspections. There were no violations cited. Should you have questions, you may contact the licensing inspector at 757-670-0504.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 2, 2021Complaint survey1 violation
Inspection dates
July 2, 2021 , July 9, 2021 , July 19, 2021 and July 22, 2021
Areas reviewed
PersonnelAdministration and Administrative ServicesResident Care and Related Services
Comments
A non-mandated complaint inspection was initiated on 07-02-2021 and concluded on 07-22-2021. A complaint was received by the department regarding allegations in the areas of Personnel, Administration and Administrative Services, and Resident Care and Related Services The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-130-B
Based on record review and interview the facility failed to notify the resident's contact person or legal representative immediately when a report of suspected abuse was made relating to the resident, as referenced in section 63.1-1606 of the Code of Virginia.
Evidence
  1. On 06-10-2021, staff #1 emailed the Licensing Inspector and indicated APS [Adult Protective Services] was in the facility on 06-09-2021 for a complaint involving allegations of name calling and abuse towards resident #2, and allegations of name calling towards resident #3 and resident #4.
  2. Staff #1 provided a copy of the residents“ ”Progress Notes? which documented: A. Resident #2’s notes dated 07-09-2021“ ”Verbal allegations per APS? This writer called and spoke with [family] trying to find out some information as to when this incident occurred?? B. Resident #3’s notes dated 07-10-2021, “POA was notified of allegations of abuse”? C. Resident #4’s notes dated 07-10-2021, “Spoke with [family] about allegation of verbal abuse”?
  3. Interviews confirmed the residents? contact persons or legal representatives were not notified of the suspected abuse immediately; nor were they informed that the alleged verbal abuse involved the resident they were affiliated with.
  4. Staff #1 could not provide documentation that the aforementioned residents? contact person or legal representative was notified of suspected abuse relating to the resident prior to 07-09-2021 or 07-10-2021. Staff #1 acknowledged the aforementioned residents? contact persons or legal representatives were not notified immediately when a report of suspected abuse was made relating to the resident.
Plan of correction
Executive Director/Designee will ensure that documentation of contact to the responsible party will be reviewed at the occurrence.
May 10, 2021Complaint survey0 violations
Inspection dates
May 10, 2021 and May 17, 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 complaint inspection was initiated on 05-10-2021 and concluded on 05-17-2021. A complaint was received by the department regarding allegations in the area of Resident Rights The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 6, 2020Inspection1 violation
Inspection dates
Nov. 6, 2020 , Nov. 9, 2020 , Nov. 13, 2020 , Dec. 1, 2020 and Dec. 2, 2020
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 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
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 11-06-2020 and concluded on 12-02-2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 68. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, criminal background checks and sworn disclosures of newly hired staff, staff schedules, fire drills, fire and health inspection reports, and healthcare oversight. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-680-D
Based on record review and interview, the facility failed to ensure medications are administered in accordance with the physician's instructions and are consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident #1’s current signed physician’s orders dated 08-25-2020 documented ?Haloperidol Lac 2 MG/ML- Take 1ML (=2MG) by mouth/under tongue every 4 hours as needed for agitation.?
  2. Resident #1’s October 2020 Medication Administration Record documented: a. Staff #6, a Registered Medication Aide (RMA), administered Haloperidol Lac 2MG/ML for “Pain in legs” on 10-04-2020 at 1:24 AM; b. Staff #7, a Licensed Practical Nurse, administered Haloperidol Lac 2MG/ML for “Anxiety” on 10-10-2020 at 1:33 AM and for “SOB” on 10-13-2020 at 4:04 PM; and c. Staff #8, a RMA, administered Haloperidol Lac 2MG/ML for “Anxiety” on 10-20-2020 at 9:17 AM.
  3. Staff #1 provided a copy of resident #1’s “Narrative Charting” [nursing notes] and the facility’s 24-hour communication log for 10-04-2020, 10-10-2020, 10-13-2020 and 10-20-2020. There was no documentation indicating that the resident was agitated on those dates. Staff #1 could not provide documentation verifying resident #1 was agitated on the aforementioned dates.
  4. Staff #8 was asked why Haloperidol 2MG/ML was administered to resident #1 for “Anxiety” on 10-20-2020 at 9:17 AM, and staff #8 stated “I do not recall the incident on 10-20-2020.”
  5. Staff #7 was asked why Haloperidol 2MG/ML was administered to resident #1 for “Anxiety” on 10-10-2020 at 1:33 AM, and for “SOB” on 10-13-2020 at 6:04 PM, and staff #7 stated ?If that is what I wrote down, that is what it was administered for.?
  6. Staff #1 acknowledged resident #1’s PRN Haloperidol Lac 2MG/ML was not administered in accordance with the physician’s instructions.
Plan of correction
Executive Director reviewed with Nurse Practitioner (NP) Resident #l's medication list. NP clarified signs and symptoms for PRN medication. Health Care Director/Designee will complete a training with staff #7 & #8 on appropriate administration of PRN medication based on reason.