Inspection Reports for Brookdale Harrisonburg
2101 Deyerle Avenue,Harrisonburg, VA, VA
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Inspection Report
Monitoring
Census: 49
Deficiencies: 0
Jul 31, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on 2025-07-17 regarding allegations in the area of medication administration.
Findings
The investigation did not support the self-report of non-compliance with standards or law. The licensing inspector reviewed medication administration records and narcotic count records and found no deficiencies.
Inspection Report
Renewal
Census: 48
Deficiencies: 2
Apr 1, 2025
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection found non-compliance with certain standards, including failure to ensure resident orientation acknowledgments were signed and failure to complete fire and emergency evacuation drills quarterly. Violation notices were issued with opportunities for the licensee to submit plans of correction.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure the acknowledgment of having received the orientation was signed by the resident. |
| The facility failed to ensure fire and emergency evacuation drills were completed quarterly. |
Report Facts
Number of residents present: 48
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 4
Fire drill dates recorded: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Gale | Licensing Inspector | Contact person for questions about the VDSS Licensing Programs |
| Angela N Via | Current Inspector | Inspector on-site during the inspection |
| Staff 1 | Interviewed staff member who confirmed deficiencies related to resident orientation signatures and fire drills | |
| Executive Director | Responsible for auditing and obtaining signed resident orientations and ensuring fire drills are completed | |
| Health and Wellness Director | Involved in auditing and obtaining signed resident orientations | |
| Maintenance Manager | Responsible for fire drill completion and calendar scheduling |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 3
Jan 29, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2024-12-19 regarding allegations related to Resident Care and Related Services, Admission and Retention of Residents, and Incidents.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, violations unrelated to the complaint were identified during the inspection, including failure to ensure prior assessment of serious cognitive impairment before admission, failure to report a major incident within 24 hours, and failure to ensure a physical examination was completed within 30 days preceding admission.
Complaint Details
Complaint was received on 2024-12-19 alleging issues in Resident Care and Related Services, Admission and Retention of Residents, and Incidents. The evidence gathered did not support the allegations of non-compliance.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure prior to admission that the resident had been assessed as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with inability to recognize danger or protect safety. |
| Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident. |
| Facility failed to ensure each resident had a physical examination completed by an independent physician within 30 days preceding admission. |
Report Facts
Number of residents present: 52
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: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Gale | Licensing Inspector | Contact person for questions about the VDSS Licensing Programs |
| Angela N Via | Licensing Inspector | Inspector on-site during the inspection |
| Executive Director | Named in plan of correction for audit of resident files and reporting incidents | |
| Health and Wellness Director | Named in plan of correction for reporting incidents | |
| Health and Wellness Coordinator | Named in plan of correction for reporting incidents | |
| Staff 1 | Interviewed staff member providing information about assessments, incidents, and physical examinations |
Inspection Report
Monitoring
Census: 42
Deficiencies: 1
Oct 3, 2024
Visit Reason
The inspection was a monitoring visit conducted on 10/03/2024 to review compliance with resident care and related services, including a self-reported incident regarding medication administration.
Findings
The investigation supported the self-report of non-compliance related to a medication error where a resident received medication prescribed for another resident. Violations were issued based on record review and staff interviews.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that medications were administered in accordance with physician instructions, resulting in a medication error where resident 1 received resident 2's Oxycodone instead of their prescribed Alprazolam. |
Report Facts
Number of residents present: 42
Number of resident records reviewed: 2
Number of staff records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Inspection Report
Monitoring
Census: 46
Deficiencies: 4
Jun 14, 2024
Visit Reason
The inspection was a monitoring visit to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found multiple violations related to failure to update fall risk ratings after falls, incomplete resident orientation documentation, failure to update Individualized Service Plans following changes in condition, and incomplete oxygen order information.
Deficiencies (4)
| Description |
|---|
| Facility failed to review and update the fall risk rating after a fall. |
| Facility failed to ensure that the orientation to the facility was signed and dated by the resident or legal representative and kept in the resident's record. |
| Facility failed to ensure the Individualized Service Plan (ISP) was updated following a change in condition. |
| Facility failed to ensure oxygen orders contain all required information. |
Report Facts
Number of residents present: 46
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Falls documented: 4
Audit percentage: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Licensing Inspector | Current inspector conducting the inspection |
| Jessica Gale | Licensing Inspector | Contact person for questions about the inspection |
| Staff 2 | Named in multiple findings related to fall risk assessments, home health services, and oxygen order requirements | |
| Staff 3 | Named in finding related to missing resident orientation documentation |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 0
Nov 17, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-10-10 regarding allegations in the areas of resident care and related services and building and grounds.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly.
Complaint Details
Complaint received on 2023-10-10 regarding resident care and building and grounds; investigation did not substantiate allegations.
Inspection Report
Monitoring
Deficiencies: 3
Jun 2, 2023
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on 05/31/2023 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with standards or law, resulting in violations issued related to failure to reassess a resident after a significant change in condition, failure to update the Individualized Service Plan, and failure to ensure supervision to prevent wandering from the premises.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure a reassessment was completed when a resident had a significant change in condition using the Uniform Assessment Instrument. |
| Facility failed to update the Individualized Service Plan when there was a significant change in the resident's condition. |
| Facility failed to ensure supervision of resident's schedules, care, and activities, including prevention of falls and wandering from the premises. |
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of staff interviewed: 1
Inspection Report
Renewal
Census: 48
Deficiencies: 5
Apr 25, 2023
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations related to individualized service plans not reflecting assessed needs, failure to include hospice services in plans, improper medication storage and administration, incomplete physician orders for oxygen, and maintenance issues such as plumbing problems and cleanliness.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure all assessed needs are identified on the Individualized Service Plan (ISP). |
| Facility failed to ensure hospice services are included on the Individualized Service Plan. |
| Facility failed to ensure no medications were in residents' rooms for a resident dependent on medication administration by staff. |
| Facility failed to ensure physician's orders for oxygen included all required components. |
| Facility failed to ensure the interior of the building is maintained in good repair and kept clean. |
Report Facts
Number of residents present: 48
Number of resident records reviewed: 10
Number of staff records reviewed: 4
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Plan of correction deadlines: May 31, 2023
Plan of correction deadlines: Aug 11, 2023
Plan of correction deadlines: Jun 1, 2023
Plan of correction deadline: May 15, 2023
Inspection Report
Monitoring
Census: 51
Deficiencies: 4
Mar 31, 2022
Visit Reason
A mandated monitoring inspection was conducted to review compliance with administrative, personnel, resident care, and other regulatory requirements.
Findings
The facility was found clean and odor-free with reviewed menus, activities, and records; however, four violations were identified related to physical examinations, Uniform Assessment Instrument completion, Individualized Service Plan completeness, and annual review requirements.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure a physical examination was completed within 30 days of admission. |
| Facility failed to ensure the Uniform Assessment Instrument is completed annually as required. |
| Facility failed to ensure the Individualized Service Plan included all required components. |
| Facility failed to ensure the Individualized Service Plan is reviewed and updated annually. |
Report Facts
Number of violations: 4
Resident census: 51
Inspection Report
Renewal
Census: 50
Deficiencies: 0
Mar 15, 2021
Visit Reason
A renewal inspection was initiated on 03/15/21 and concluded on 03/31/21 to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection determined no violations with applicable standards or law. No violations were issued during this desk review process.
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