Inspection Reports for
Aviva Pembroke
373 Constitution Drive, VIRGINIA BEACH, VA, 23462
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Inspection Reports Summary
Covers 9 inspections · Nov 2024 – May 2026Visit Reason
This report covers 9 inspections of Aviva Pembroke from November 22, 2024 to May 14, 2026, including routine and complaint investigations.
Complaint Details
Four inspections were complaint surveys prompted by complaints regarding Resident Care and Related Services and the Safe Secure Environment. Investigations supported some but not all allegations; violation notices were issued.
Findings
Across that history VDSS cited 35 violations under 25 distinct standards. Four inspections were prompted by a complaint.
Violations (34)
22VAC40-73-450-A: Failed to ensure preliminary plan of care developed on or within seven days prior to admission.
22VAC40-73-450-D: Failed to ensure coordinated plan of care with hospice services included in ISP.
22VAC40-73-970-A: Fire and emergency evacuation drills not held in compliance with fire code.
22VAC40-73-390-A: Admission agreement missing signature or date by licensee or administrator.
22VAC40-73-1090-A: Assessment missing documentation of inability to recognize danger or protect safety.
22VAC40-73-1140-B: Direct care staff did not complete required 10 hours cognitive impairment training within four months.
22VAC40-73-320-A: Physical exam missing date, height, weight, TB risk assessment, or statement on care needs.
22VAC40-73-490-B: Licensed health care professional failed to provide required health care oversight.
22VAC40-73-250-D: Staff tuberculosis risk assessment not completed on or within seven days prior to first work day.
22VAC40-73-450-C: ISP missing date needs identified and expected outcome with timeframe.
22VAC40-90-40-B: Criminal history record report not obtained within 30 days of employment or contains errors.
22VAC40-90-40-C: Employed person with barrier crime convictions not ineligible for employment.
22VAC40-73-930-D: Failed to document rounds every two hours for residents unable to use signaling device.
22VAC40-73-450-C: ISP missing description of identified needs and date identified based on UAI.
22VAC40-73-920-D: Grab bars not installed by toilets in safe secure environment bathrooms.
22VAC40-73-680-C: Medications not administered within one hour before or after scheduled time.
22VAC40-73-450-E: ISP not signed and dated by licensee/administrator and resident or legal representative.
22VAC40-73-680-I: MAR missing dosage and diagnosis or specific indications for drugs or supplements.
22VAC40-73-450-C: ISP missing description of identified needs and date identified based on UAI and other sources.
22VAC40-73-680-D: Medications not administered according to physician's or prescriber's instructions.
22VAC40-73-300-B: Failed to utilize written communication to keep direct care staff informed of significant happenings.
22VAC40-73-250-D: Staff tuberculosis risk assessment not completed within required timeframe or outdated.
22VAC40-73-220-B: Failed to meet requirements for private duty personnel providing direct care or companion services.
22VAC40-73-1120-B: Less than 21 hours of scheduled activities weekly; no activities on Sundays in safe secure unit.
22VAC40-73-520-E: Less than 14 hours of scheduled activities weekly; no activities on Saturdays in assisted living.
22VAC40-73-970-E: Fire and emergency evacuation drill records missing required details.
22VAC40-73-1130-A: Less than two awake direct care staff on duty during day in special care unit with 20 or fewer residents.
22VAC40-73-930-D: Failed to ensure rounds every two hours for residents unable to use signaling device at night.
22VAC40-73-660-A-1: Medication cart was unlocked and unattended.
22VAC40-73-450-A: Preliminary plan of care not developed within seven days prior to admission for resident.
22VAC40-73-250-D: Staff tuberculosis risk assessment missing or outdated for new hires.
22VAC40-73-680-I: MAR missing diagnosis for multiple medications for several residents.
22VAC40-73-450-E: ISP not signed and dated by licensee/administrator and resident or legal representative on updates.
22VAC40-73-450-C: ISP missing description of identified needs and date identified for multiple residents.
Report Facts
Violations cited: 35
Distinct standards: 25
Inspections on page: 9
Inspections with violations: 6
Complaint visits: 4
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