1 Inspection Summary
Inspection Reports Summary
Covers 16 inspections · Nov 2020 – Dec 2025Visit Reason
This report covers 16 inspections of Harmony at Oakbrooke from November 6, 2020 to December 29, 2025, including routine, complaint, monitoring, and renewal inspections.
Complaint Details
Nine inspections were prompted by complaints. Investigations sometimes supported allegations resulting in violations, while others found no non-compliance with standards or law.
Findings
Across that history VDSS cited 45 violations under 32 distinct standards. 10 of the 16 visits ended with violations cited and 6 with none. 9 inspections were prompted by a complaint.
Violations (44)
22VAC40-73-680-D: Medications not administered per physician's instructions and nursing standards.
22VAC40-73-640-A: Failed to implement medication management plan for controlled substance counts at shift changes.
22VAC40-73-940-A: Facility failed to ensure annual fire inspection by appropriate official.
22VAC40-73-210-B: Direct care staff did not attend required annual training hours.
22VAC40-73-325-B: Fall risk assessments not reviewed or updated after resident falls.
22VAC40-73-640-A: Medication management plan not followed for timely medication refills causing missed doses.
22VAC40-73-450-C: Individualized service plan missing required elements including outcome dates.
22VAC40-73-640-A: Failed to ensure accurate counts of controlled substances during medication staff changes.
22VAC40-73-680-C: Medications administered outside one hour before or after scheduled times.
22VAC40-73-40-B: Criminal history record report not obtained within 30 days of employment for staff.
22VAC40-73-430-H-1: Discharge statement missing required information for resident.
22VAC40-73-290-B: Failed to post name of current on-site person in charge.
22VAC40-73-450-F: Individualized service plan did not accurately describe all resident needs/services.
22VAC40-73-640-A: Medication management plan not followed causing missed medication doses.
22VAC40-73-640-A: Controlled medication counts incomplete or missing for all days reviewed.
22VAC40-80-120-E-2: Failed to post findings of most recent inspection of the facility.
22VAC40-73-260-A: Direct care staff did not have first aid certification within 60 days of employment.
22VAC40-73-260-A: Direct care staff failed to maintain current first aid certification.
22VAC40-73-640-A: Failed to implement medication management plan for controlled substance counts at shift changes.
22VAC40-73-650-A: Medication or treatment changes lacked valid physician orders.
22VAC40-73-1070-A: Harmful materials accessible to residents with serious cognitive impairment without supervision.
22VAC40-73-1090-A: Residents admitted to safe, secure unit lacked required clinical assessment for serious cognitive impairment.
22VAC40-73-450-C: Comprehensive individualized service plans not completed within 30 days of admission.
22VAC40-73-320-B: Annual tuberculosis risk assessments not completed for residents.
22VAC40-73-460-H: Personal care including bathing not provided as necessary or documented.
22VAC40-73-450-E: Individualized service plans not updated annually or after significant resident changes.
22VAC40-73-250-C: Staff files missing signed current job descriptions.
22VAC40-73-310-H: Facility admitted or retained individuals without required documentation for prohibitive conditions.
22VAC40-73-440-A: Uniform assessment instruments not completed annually as required.
22VAC40-73-610-B: Weekly menu not posted; daily menus outdated.
22VAC40-73-290-B: Failed to post name of current on-site person in charge.
22VAC40-73-320-A: Physical examination including TB risk assessment not completed within 30 days prior to admission.
22VAC40-73-640-A: Medication management plan not followed causing missed medication doses.
22VAC40-73-580-D: Individualized service plan did not indicate approximate meal time needed for dependent resident.
22VAC40-73-930-D: Two-hour documented rounds in memory care were not conducted properly or timed correctly.
22VAC40-73-440-B: Uniform assessment instrument forms lacked required administrator or designee signature.
22VAC40-73-1130-C: Night staffing in special care unit below required awake staff levels.
22VAC40-73-680-C: Medications administered late frequently over multiple months.
22VAC40-73-450-E: Individualized service plan not signed by resident or legal representative.
22VAC40-73-870-B: Facility failed to maintain building free from foul, stale, and musty odors.
22VAC40-73-870-A: Facility interior and exterior not maintained in good repair; stained carpet and furniture.
22VAC40-73-150-B: Facility failed to immediately employ or appoint qualified administrator after vacancy.
22VAC40-73-290-B: Failed to post name of current on-site person in charge in conspicuous place.
22VAC40-73-130-B: Failed to notify resident's contact or legal representative immediately of suspected abuse reports.
Report Facts
Violations cited: 45
Distinct standards: 32
Inspections on page: 16
Inspections with violations: 10
Complaint visits: 9
Employees mentioned
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