Inspection Reports for Aviva Pembroke
373 Constitution Drive, VIRGINIA BEACH, VA, 23462
Back to Facility ProfileDeficiencies (last 2 years)
Deficiencies (over 2 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% worse than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
33 residents
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 0
Date: Oct 10, 2025
Visit Reason
An unannounced complaint inspection was conducted on October 10, 2025, following a complaint received on September 16, 2025, regarding allegations in the area of Resident Care and Related Services.
Complaint Details
Complaint received by VDSS Division of Licensing on 09/16/25 regarding allegations in Resident Care and Related Services. The investigation did not substantiate the complaint.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No deficiencies were cited.
Report Facts
Number of residents present: 33
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 4
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Date: Sep 9, 2025
Visit Reason
An unannounced complaint inspection was conducted on 09/09/2025 following a complaint received on 08/16/2025 regarding allegations in the areas of Staffing and Supervision, Resident Care and Related Services, and Safe Secure Environment.
Complaint Details
The complaint was substantiated in part, with non-compliance found in Resident Care and Related Services related to medication administration timing.
Findings
The investigation supported some of the allegations, specifically non-compliance in Resident Care and Related Services. A violation was found related to medication administration timing, where medications were administered more than one hour after the scheduled time.
Deficiencies (1)
The facility failed to ensure medications were administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, as evidenced by medication pass observations and record reviews showing late administration.
Report Facts
Number of residents present: 34
Number of resident records reviewed: 3
Number of staff records reviewed: 2
Number of resident interviews: 3
Number of staff interviews: 2
Medication administration time deviation: 90
Medication administration time deviation: 113
Plan of correction audit frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Conducted the inspection and is contact for questions |
| Staff #2 | Interviewed and confirmed late medication administration for residents |
Inspection Report
Renewal
Census: 28
Deficiencies: 11
Date: Apr 24, 2025
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations including insufficient scheduled activities, inadequate oversight of private duty personnel, incomplete tuberculosis risk assessments, lack of written communication among staff, incomplete individualized service plans, medication administration errors, missing diagnoses on medication administration records, inconsistent resident rounding documentation, and incomplete fire and emergency drill records.
Deficiencies (11)
Facility failed to ensure at least 21 hours of scheduled activities weekly with no less than two hours daily; no activities scheduled on Sundays.
Facility failed to meet requirements for private duty personnel who are not employees of a licensed home care organization providing direct care or companion services.
Facility failed to ensure each staff person and household member submit a tuberculosis risk assessment within 30 days prior to contact with residents.
Facility failed to utilize a written communication method to keep direct care staff informed of significant happenings or problems.
Comprehensive individualized service plans (ISP) lacked descriptions of identified needs and dates based on assessments.
Individualized service plans were not signed and dated by the licensee, administrator, or resident/legal representative upon review and updates.
Facility failed to ensure at least 14 hours of scheduled activities weekly with no less than one hour daily; no activities scheduled on Saturdays.
Medications were not administered according to physician's orders, including missed doses and administration despite parameters to hold.
Medication administration records (MAR) lacked dosage and diagnosis or specific indications for administering drugs or supplements.
Memory Care 2-hour check logs were not consistently completed documenting resident rounds as required.
Records of required fire and emergency evacuation drills lacked key information including name of person conducting drill, number of residents participating, time to complete drill, and weather conditions.
Report Facts
Number of residents present: 28
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of interviews with residents: 3
Number of interviews with staff: 3
Hours of scheduled activities required weekly: 21
Hours of scheduled activities required weekly: 14
Medications missing diagnosis on MAR: 18
Medications missing diagnosis on MAR: 8
Medications missing diagnosis on MAR: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #3 | Mentioned in relation to missing tuberculosis risk assessment | |
| Staff #4 | Confirmed no scheduled activities on Sundays and Saturdays | |
| Staff #5 | Acknowledged issues with private duty personnel, missing DNRs, incomplete ISPs, and lack of written communication | |
| Staff #6 | Confirmed Staff #3 lacks completed TB risk assessment |
Inspection Report
Monitoring
Census: 31
Deficiencies: 0
Date: Mar 27, 2025
Visit Reason
The inspection was a monitoring visit to measure units for a license modification request and to review resident accommodations and building grounds.
Findings
The inspection found no violations with applicable standards or laws during the tour of the physical plant including the building and grounds.
Inspection Report
Monitoring
Census: 21
Deficiencies: 8
Date: Jan 28, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection identified multiple violations including insufficient direct care staff on the special care unit, outdated tuberculosis risk assessments for staff, incomplete preliminary plans of care, missing documentation and signatures on individualized service plans, unlocked medication cart, incomplete medication administration records, and lack of documentation for required resident rounds.
Deficiencies (8)
Facility failed to ensure at least two direct care staff members were awake and on duty at all times in the special care unit except during night hours when 20 or fewer residents are present.
Facility failed to ensure staff and household members submitted tuberculosis risk assessments within 7 days prior to first workday or resident contact.
Facility failed to develop a preliminary plan of care within seven days of admission for Resident #2.
Comprehensive individualized service plans (ISP) did not include descriptions of identified needs, dates identified, or were inconsistent with assessment information.
ISPs of Residents #1, #3, and #4 were not signed and dated by the licensee, administrator, or legal representative.
Medication cart was found unlocked and unattended during observation.
Medication administration records (MAR) lacked diagnosis or indication for multiple medications for Residents #1, #3, #4, and #5.
Facility failed to document that direct care staff made rounds at least every two hours for residents unable to use signaling devices during night hours.
Report Facts
Number of residents present: 21
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of interviews with residents: 3
Number of interviews with staff: 3
Inspection Report
Original Licensing
Deficiencies: 0
Date: Nov 22, 2024
Visit Reason
The inspection was an initial licensing inspection conducted to evaluate the facility for licensing approval.
Findings
The inspection found no violations of applicable standards or laws. The inspector completed a tour of the physical plant and reviewed first aid kits and required postings.
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