Inspection Reports for Harmony at Harbour View
5871 Harbour View Blvd, Suffolk, VA 23435, United States, VA, 23435
Back to Facility ProfileDeficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Monitoring
Census: 80
Deficiencies: 0
Oct 7, 2025
Visit Reason
An unannounced monitoring inspection was conducted following a self-report received regarding allegations in the areas of Personnel and Resident Care and Related Services.
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 and a copy is required to be posted on the facility premises.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 4
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 0
Oct 7, 2025
Visit Reason
The inspection was conducted due to a complaint received by VDSS Division of Licensing on 2025-09-15 regarding allegations in the areas of Resident Care and Related Services, The Safe Secure Unit, and Building and Grounds.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant and conducted interviews with staff.
Complaint Details
Complaint was received on 2025-09-15 regarding Resident Care and Related Services, The Safe Secure Unit, and Building and Grounds. The investigation did not substantiate the allegations.
Report Facts
Number of residents present: 80
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 4
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Oct 7, 2025
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2025-09-10 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported some, but not all, of the allegations. The facility was found non-compliant in Resident Care and Related Services, specifically failing to ensure medications were administered according to physician or prescriber instructions.
Complaint Details
Complaint related: Yes. The complaint was substantiated in part, with non-compliance found in Resident Care and Related Services.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions, as evidenced by missed medications for resident #4 on 09/07/25 and 09/08/25 without proper documentation. |
Report Facts
Residents present: 80
Resident records reviewed: 4
Staff records reviewed: 0
Resident interviews conducted: 3
Staff interviews conducted: 4
Medication audit period: 30
MAR audit monitoring period: 90
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Oct 7, 2025
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2025-09-23 regarding allegations in Resident Care and Related Services.
Findings
The investigation supported some of the allegations related to Resident Care and Related Services, specifically delayed staff response times to resident needs. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.
Complaint Details
The complaint was substantiated in part; evidence showed resident #2 experienced delayed staff response times exceeding 45 minutes on multiple occasions in September 2025, resulting in unmet needs such as toileting and dressing.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure care provision and service delivery was resident-centered, including prompt response by staff to resident needs as reasonable to the circumstances. |
Report Facts
Residents present: 80
Resident records reviewed: 4
Staff records reviewed: 0
Resident interviews conducted: 3
Staff interviews conducted: 4
Emergency pendant response delays: 4
Plan of Correction Completion Date: Dec 24, 2025
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
Aug 26, 2025
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2025-08-11 regarding allegations in the areas of Buildings and Grounds.
Findings
The investigation did not support the allegations of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant including buildings and grounds, and observed entrance and exit doors.
Complaint Details
Complaint was received by VDSS Division of Licensing on 2025-08-11 regarding allegations in Buildings and Grounds. The evidence gathered did not support the allegations of non-compliance.
Report Facts
Number of residents present: 82
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: 4
Inspection Report
Renewal
Census: 81
Deficiencies: 10
Jul 22, 2025
Visit Reason
An unannounced renewal inspection was conducted on July 22 and July 23, 2025, to assess compliance with licensing requirements for the assisted living facility.
Findings
The inspection identified multiple violations related to admission procedures, resident assessments, individualized service plans, medication administration, and medication storage. Corrective actions and systemic changes were required to address these deficiencies.
Deficiencies (10)
| Description |
|---|
| Failed to ensure written assurance of appropriate license was provided and signed by resident prior to admission. |
| Failed to ascertain and document sex offender screening prior to admission for residents with anticipated stay over three days. |
| Failed to provide and document orientation for new residents and their legal representatives upon admission. |
| Failed to ensure annual completion of the Uniform Assessment Instrument (UAI) for residents. |
| Failed to develop a preliminary plan of care on or within 7 days prior to admission or a comprehensive individualized service plan (ISP) on admission day. |
| Failed to include date identified, expected outcome, and timeframe in the individualized service plan (ISP). |
| Failed to ensure the individualized service plan (ISP) was signed and dated by the licensee/administrator and resident or legal representative. |
| Failed to review and update the individualized service plan (ISP) at least annually or as needed for significant changes. |
| Failed to administer medications according to physician orders and document reasons for missed medications. |
| Failed to ensure PRN medications were available, properly labeled, and stored for residents. |
Report Facts
Residents present: 81
Resident records reviewed: 6
Staff records reviewed: 3
Resident interviews conducted: 3
Staff interviews conducted: 7
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 3
Jul 22, 2025
Visit Reason
An unannounced complaint inspection was conducted on July 22-23, 2025, following a complaint received on July 18, 2025, regarding allegations in the areas of Personnel, Resident Care and Related Services, and The Safe Secure Environment.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Personnel and the Safe Secure Unit. Violations were found related to oversight and documentation of private duty personnel services and failure to document required two-hour resident rounds for a resident unable to use signaling devices.
Complaint Details
The complaint was substantiated in part, with violations found in Personnel and Safe Secure Unit areas. The complaint investigation was triggered by allegations received on July 18, 2025.
Deficiencies (3)
| Description |
|---|
| Failure to ensure private duty personnel from licensed home care organizations had required documentation including service type and frequency, tuberculosis examination, and orientation/training. |
| Failure to ensure private duty personnel not employed by licensed home care organizations had required documentation including service type and frequency, tuberculosis examination, qualifications, criminal history, and orientation/training. |
| Failure to document two-hour rounds for resident #2 who is unable to use signaling device on multiple dates in May, June, and July 2025. |
Report Facts
Residents present: 81
Resident records reviewed: 2
Staff interviews conducted: 5
Dates of missing 2-hour rounds: 6
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 0
Jul 15, 2025
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2025-07-08 regarding allegations in the areas of Administration and Administrative Services and Personnel.
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 within 5 business days.
Complaint Details
Complaint received on 2025-07-08 regarding Administration and Administrative Services and Personnel; investigation did not substantiate the allegations.
Report Facts
Residents present: 80
Staff records reviewed: 2
Resident interviews: 2
Staff interviews: 2
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 0
Jul 15, 2025
Visit Reason
An unannounced complaint inspection was conducted due to a complaint received on 2025-07-08 regarding allegations in the areas of Administration and Administrative Services, Personnel, Staffing and Supervision, and Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection included a tour of the facility, observations of residents and supplies, and review of staffing schedules.
Complaint Details
Complaint received by VDSS Division of Licensing on 2025-07-08 regarding allegations in Administration and Administrative Services, Personnel, Staffing and Supervision, and Resident Care and Related Services. The complaint was not substantiated.
Report Facts
Number of residents present: 80
Number of resident records reviewed: 0
Number of staff records reviewed: 2
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Deficiencies: 0
Jul 15, 2025
Visit Reason
An unannounced monitoring inspection was conducted to determine whether the provider had corrected or was in the process of correcting previously cited violations in the areas of administration and resident care.
Findings
The inspection yielded no violations of applicable laws or regulations.
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 0
Jul 15, 2025
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2025-07-08 regarding allegations in the areas of Administration and Administrative Services and Personnel.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. Residents were observed in common areas and dining, and a review of the facility's weapons policy was completed.
Complaint Details
Complaint received on 2025-07-08 regarding Administration and Administrative Services and Personnel; investigation did not substantiate allegations.
Report Facts
Number of residents present: 80
Number of staff records reviewed: 2
Number of interviews conducted with staff: 2
Number of resident records reviewed: 0
Number of interviews conducted with residents: 0
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 5
Jun 10, 2025
Visit Reason
An unannounced complaint inspection was conducted on June 10 and June 25, 2025, following a complaint received on May 25, 2025, regarding allegations in the areas of Administration and Administrative Services and Resident Care and Related Services.
Findings
The investigation found multiple violations including failure to notify hospice care of resident incidents, inadequate documentation of staff training and certifications, delayed staff response to resident call bells, failure to provide personalized care and supervision leading to a resident fall and subsequent death. Violations were substantiated and corrective actions were required.
Complaint Details
The complaint was substantiated based on evidence including resident records, staff interviews, video footage, incident reports, and collateral contacts. Violations related to failure to notify hospice, inadequate training documentation, lack of first aid certification, delayed call bell response, and insufficient supervision leading to resident injury and death were confirmed.
Deficiencies (5)
| Description |
|---|
| Failure to notify hospice care agency of resident incidents including pain and emergency calls. |
| Failure to maintain documentation of required staff training including type, provider, hours, and dates. |
| Failure to ensure direct care staff maintain current certification in first aid. |
| Failure to provide prompt response to resident call bell alerts, resulting in delayed assistance. |
| Failure to provide adequate supervision and care, resulting in resident fall and injury leading to death. |
Report Facts
Residents present: 79
Resident records reviewed: 3
Staff records reviewed: 6
Staff interviews conducted: 8
Dates of inspection: 2025-06-10 and 2025-06-25
Resident #1 fall date: May 12, 2025
Resident #1 death date: May 20, 2025
Plan of correction completion date: Oct 15, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the complaint investigation. |
| Staff #2 | Confirmed failure to notify hospice care agency of resident incidents. | |
| Staff #3 | Confirmed response to resident fall and provided information in updated incident report. | |
| Staff #6 | Involved in delayed response to resident call bell alert. | |
| Staff #7 | Failed to provide requested physical assistance to resident. | |
| Staff #8 | Failed to provide requested physical assistance to resident. | |
| Staff #10 | Confirmed lack of documentation for staff training and first aid certification. | |
| Administrator | Responsible for oversight of compliance and implementation of corrective actions. | |
| BOM | Responsible for maintenance of training records and certification tracking. | |
| HCD | Responsible for staff training, monitoring, care plan audits, and ongoing monitoring. |
Inspection Report
Monitoring
Census: 85
Deficiencies: 1
May 20, 2025
Visit Reason
An unannounced monitoring inspection was conducted following a self-report received by VDSS Division of Licensing regarding allegations in the areas of Resident Care and Related Services and the Safe Secure Environment.
Findings
The inspection found non-compliance with standards related to supervision of residents, specifically failure to prevent a resident with dementia from leaving the safe secure environment unsupervised for 15 minutes. A violation notice was issued and the facility was given the opportunity to submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure supervision of resident schedules, care, and activities, including prevention of falls and wandering from the premises. |
Report Facts
Number of residents present: 85
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 3
Date of incident: Apr 21, 2025
Duration of unsupervised exit: 15
Plan of correction completion date: Jul 11, 2025
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 2
Apr 22, 2025
Visit Reason
An unannounced complaint inspection was conducted due to complaints received on 2025-04-02 and 2025-04-14 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Resident Care and Related Services. Violations related to medication storage and Medication Administration Record (MAR) documentation were found.
Complaint Details
Complaint related to Resident Care and Related Services; evidence supported some allegations. A violation notice was issued. The complaint was substantiated in part.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medications remained in the pharmacy issued container with prescription label until administered. |
| Facility failed to ensure the Medication Administration Record (MAR) included any medication errors or omissions. |
Report Facts
Residents present: 76
Resident records reviewed: 2
Staff records reviewed: 1
Staff interviews conducted: 4
Inspection duration: 223
Audit period: 60
Audit period: 60
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 1
Mar 31, 2025
Visit Reason
An unannounced complaint inspection was conducted due to a complaint received on 2025-03-06 regarding allegations in the areas of Staffing and Supervision, and Resident Care and Related Services.
Findings
The investigation supported some, but not all, of the allegations; non-compliance was found in Resident Care and Related Services. A violation notice was issued related to medication administration documentation.
Complaint Details
The complaint was substantiated in part, with non-compliance found in Resident Care and Related Services. The complaint was related to Staffing and Supervision and Resident Care and Related Services.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that medication administration was documented on the medication administration record (MAR) at the time medications were administered to residents. |
Report Facts
Residents present: 76
Resident records reviewed: 5
Staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Jan 30, 2025
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2025-01-29 regarding allegations in the areas of Resident Care and Related Services and Buildings and Grounds.
Findings
The investigation did not support the allegations of non-compliance with standards or law. The licensing inspector conducted a tour of the physical plant and observations of heaters and temperatures in resident rooms and common areas.
Complaint Details
Complaint received by VDSS Division of Licensing on 01/29/2025 regarding allegations in Resident Care and Related Services and Buildings and Grounds. The evidence gathered did not support the allegations.
Report Facts
Number of residents present: 85
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
Inspection Report
Monitoring
Census: 85
Deficiencies: 11
Jan 30, 2025
Visit Reason
An unannounced monitoring inspection was conducted on January 30, 2025 and February 28, 2025 following a self-report received by VDSS regarding allegations in the area of Resident Care and Related Services.
Findings
The inspection found multiple violations including failure to post the current license conspicuously, incomplete staff tuberculosis risk assessments, expired first aid certifications, inadequate staffing plans, incomplete and outdated resident records, failure to secure immediate medical attention for a resident in distress, medication administration timing errors, expired elevator inspection certificates, and lack of documentation of staff review of emergency procedures.
Deficiencies (11)
| Description |
|---|
| Facility failed to ensure the current license is posted in a place conspicuous to residents and the public. |
| Facility failed to ensure each staff person annually submits tuberculosis risk assessment documentation. |
| Facility failed to ensure each direct care staff member maintains current certification in first aid. |
| Facility failed to maintain a written staffing plan specifying number and type of direct care staff based on resident acuity and needs. |
| Resident personal and social information was not current or complete in the resident record. |
| Individualized service plan (ISP) was not signed and dated by resident or legal representative. |
| Facility failed to secure immediate medical attention and notify physician when resident suffered serious incident and refused ER visit. |
| Resident record lacked physician's signed written order for use of CPAP for obstructive sleep apnea. |
| Medications were administered outside the facility's standard dosing schedule by more than one hour on multiple dates. |
| Elevator certificate of inspection was expired and current certificate was pending issuance. |
| Facility failed to ensure staff reviewed and signed the resident emergency plan at least every six months. |
Report Facts
Number of residents present: 85
Number of resident records reviewed: 1
Number of staff records reviewed: 3
Number of staff interviews conducted: 7
Dates medications administered late: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the monitoring inspection |
| Staff 1 | Mentioned in relation to missing TB risk assessment, emergency plan review, and resident incident | |
| Staff 3 | Mentioned in relation to missing first aid certification, emergency plan review, and resident incident | |
| Staff 5 | Mentioned in relation to resident record and medication administration | |
| Staff 6 | Interviewed regarding TB risk assessment and emergency plan | |
| Staff 7 | Provided staffing plan and confirmed elevator certificate status | |
| Executive Director | Executive Director | Responsible for monitoring license posting and corrective actions |
| Business Office Manager | Responsible for ensuring TB risk assessments and first aid certifications | |
| Healthcare Director | Responsible for resident records, emergency procedures, medication administration, and corrective actions |
Inspection Report
Monitoring
Census: 85
Deficiencies: 3
Jan 30, 2025
Visit Reason
An unannounced monitoring inspection was conducted on January 30, 2025 and February 28, 2025 to review compliance with applicable standards and laws, following a self-report received regarding allegations in Resident Care and Related Services.
Findings
The inspection found non-compliance with several standards related to resident care, including failure to ensure general responsibility for residents' health and safety, failure to regularly observe and document changes in residents' conditions, and failure to document required two-hour rounds for residents with inability to use signaling devices.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure general responsibility for the health, safety, and well-being of residents, including failure to notify licensed healthcare professional of resident's hip pain and lack of assessment. |
| Facility failed to regularly observe and document changes in physical, mental, emotional, and social functioning of residents, including lack of documentation of resident complaints and symptoms. |
| Facility failed to ensure required minimal frequency of daily rounds (every two hours) for residents unable to use signaling devices and failed to document these rounds properly. |
Report Facts
Number of residents present: 85
Number of resident records reviewed: 1
Number of staff interviews conducted: 4
Dates missing documented 2-hour rounds: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the monitoring inspection |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 2
Dec 20, 2024
Visit Reason
An unannounced complaint inspection was conducted following complaints received on 12/13/2024 and 12/19/2024 regarding personnel, resident care and related services, and the safe secure environment.
Findings
The investigation supported some but not all allegations of non-compliance related to Resident Care and Related Services. Violations were found related to medication storage and failure to document required two-hour rounds for a resident with dementia.
Complaint Details
Complaint was received by VDSS Division of Licensing on 12/13/2024 and 12/19/2024 regarding allegations in personnel, resident care and related services, and safe secure environment. Evidence supported some non-compliance in Resident Care and Related Services.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medications were stored in a manner consistent with current standards; medication cart on 3rd floor was unlocked and unstaffed. |
| Facility failed to ensure required two-hour rounds were documented for resident with dementia during specified dates and times. |
Report Facts
Number of residents present: 85
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 3
Dec 10, 2024
Visit Reason
An unannounced complaint inspection was conducted due to allegations received on 2024-12-02 regarding staffing and supervision, and resident care and related services at the facility.
Findings
The investigation supported some but not all allegations, identifying non-compliance in staffing levels during night hours, documentation requirements for private duty personnel, and elevator inspection certification. A violation notice was issued.
Complaint Details
The complaint was substantiated in part, with violations found related to staffing and supervision and resident care. Some allegations were not supported.
Deficiencies (3)
| Description |
|---|
| During night hours, the facility had only 2 direct care staff scheduled in the special care unit instead of the required 3 for 23 residents. |
| The facility failed to ensure required documentation for private duty personnel not employed by a licensed home care organization, including tuberculosis exams, training, service documentation, qualifications, and criminal history reports. |
| The elevator's certificate of inspection expired on 2024-05-31 and the facility is awaiting a new certificate from the local building official. |
Report Facts
Number of residents present: 88
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of resident interviews conducted: 2
Number of staff interviews conducted: 3
Required direct care staff during night shift: 3
Actual direct care staff scheduled during night shift: 2
Documented census for special care unit: 23
Expired elevator inspection certificate date: May 31, 2024
Inspection Report
Monitoring
Census: 84
Deficiencies: 0
Nov 15, 2024
Visit Reason
An unannounced monitoring inspection was conducted following a self-report received by VDSS Division of Licensing regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not support the self-report of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant and conducted interviews and observations without identifying deficiencies.
Report Facts
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
Inspection Report
Monitoring
Census: 84
Deficiencies: 2
Oct 29, 2024
Visit Reason
An unannounced monitoring inspection was conducted on October 29, 2024 and November 15, 2024 to review compliance with regulations and investigate a self-report received regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with regulations, resulting in violations related to the facility's failure to ensure compliance with vehicle safety policies and general responsibility for resident health and safety. Specifically, a resident was injured during transport on the facility's community bus due to failure to secure the resident with a seatbelt.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure compliance with all regulations and its own vehicle safety program policies, including missing motor vehicle reports, missing driver acknowledgements, and lack of initial safe driver training documentation for staff. |
| Facility failed to ensure general responsibility for the health, safety, and well-being of residents, evidenced by a resident being thrown from a wheelchair during transport and sustaining injuries due to not being secured with a seatbelt. |
Report Facts
Number of residents present: 84
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 3
Incident date: Oct 23, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Current inspector conducting the monitoring inspection |
| Staff #1 | Named in findings related to failure to secure resident with seatbelt and involved in incident on community bus | |
| Executive Director | Responsible for ensuring compliance and re-education of drivers as part of plan of correction |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 3
Oct 29, 2024
Visit Reason
An unannounced complaint inspection was conducted due to complaints received on 10/08/2024 and 10/28/2024 regarding allegations in the areas of Personnel, Staffing and Supervision, and Resident Care and Related Services.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Personnel and Resident Care and Related Services. Violations included insufficient annual training hours for direct care staff, delayed staff response to resident call pendants, and failure to ensure staff reviewed emergency procedures every six months.
Complaint Details
Complaint related: Yes. The complaint was substantiated in part, with violations found in Personnel and Resident Care and Related Services.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure all direct care staff attended at least 18 hours of annual training. |
| Facility failed to provide resident-centered care with prompt staff response to resident call pendants. |
| Facility failed to ensure staff reviewed the plan for resident emergencies at least every six months. |
Report Facts
Number of residents present: 84
Number of resident records reviewed: 3
Number of staff records reviewed: 2
Number of resident interviews conducted: 5
Number of staff interviews conducted: 4
Annual training hours documented for staff #1: 8.75
Annual training hours documented for staff #2: 1
Call pendant wait times for resident #1: 75
Call pendant wait times for resident #1: 106
Call pendant wait times for resident #1: 118
Call pendant wait times for resident #1: 80
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 2
Oct 29, 2024
Visit Reason
An unannounced complaint inspection was conducted due to a complaint received on 2024-10-17 regarding allegations in Resident Care and Related Services and Buildings and Grounds.
Findings
The investigation supported some but not all allegations, identifying non-compliance with standards related to failure to regularly observe residents for changes in condition and failure to secure immediate medical attention and document incidents properly. A violation notice was issued.
Complaint Details
Complaint related: Yes. The complaint was received by VDSS Division of Licensing on 2024-10-17 regarding Resident Care and Related Services and Buildings and Grounds. The evidence supported some but not all allegations.
Deficiencies (2)
| Description |
|---|
| Facility failed to regularly observe each resident for changes in physical, mental, emotional, and social functioning, and failed to document notable changes including illness, injury, or altered behavior in the resident's record. |
| Facility failed to ensure immediate medical attention was secured when a resident suffered serious illness and failed to document the circumstances and medical attention received or refused in the resident's record. |
Report Facts
Number of residents present: 84
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 5
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Census: 86
Deficiencies: 1
Oct 2, 2024
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with regulations following a self-report received by VDSS regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with regulations, resulting in violations issued related to failure to ensure proper assessments for residents using motorized mobility aids. Additional violations not related to the self-report were also identified.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure compliance with all regulations and terms of the license, including failure to conduct required assessments by rehab personnel for residents using motorized wheelchairs. |
Report Facts
Number of residents present: 86
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: 1
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 7
Oct 2, 2024
Visit Reason
An unannounced complaint inspection was conducted on October 2 and October 29, 2024, following a complaint received on September 23, 2024, regarding allegations in the areas of Personnel, Resident Care and Related Services, and Safe Secure Environment.
Findings
The investigation supported some but not all allegations of non-compliance, specifically in Resident Care and Related Services. Multiple violations were identified related to staff qualifications, training, tuberculosis screening, individualized service plans, and resident monitoring rounds.
Complaint Details
Complaint received on 2024-09-23 regarding Personnel, Resident Care and Related Services, and Safe Secure Environment. Evidence supported some allegations related to Resident Care and Related Services.
Deficiencies (7)
| Description |
|---|
| Facility failed to obtain documentation of staff qualifications for personal care aide as required. |
| Direct care staff did not complete at least 18 hours of annual training. |
| Staff training did not include at least two hours focusing on infection control and prevention. |
| Staff records lacked timely tuberculosis risk assessment documentation prior to first day of work. |
| Direct care staff did not have certification in first aid within 60 days of employment. |
| Individualized service plan was not signed and dated by resident or legal representative. |
| Facility failed to document required two-hour rounds for residents with inability to use signaling devices on specified dates. |
Report Facts
Residents present: 86
Resident records reviewed: 2
Staff records reviewed: 2
Staff interviews conducted: 4
Training hours documented: 3
Dates missing 2-hour rounds: 2
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 2
Aug 12, 2024
Visit Reason
An unannounced complaint inspection was conducted due to allegations related to Staffing and Supervision, and Resident Care and Related Services received by VDSS Division of Licensing on 2024-08-01.
Findings
The investigation supported some of the allegations related to Resident Care and Related Services. Violations were found regarding failure to complete preliminary plans of care within 7 days of admission and failure to document required two-hour rounds for residents unable to use signaling devices.
Complaint Details
The complaint was substantiated in part, specifically regarding Resident Care and Related Services. Allegations involved Staffing and Supervision and Resident Care. A violation notice was issued.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure a preliminary plan of care was developed on or within 7 days prior to admission or an ISP on the day of admission for residents #1 and #2. |
| Facility failed to document two-hour rounds for resident #2 during the 11pm to 7am shift on 8/11/24 to 8/12/24 as required for residents unable to use signaling devices. |
Report Facts
Number of residents present: 86
Number of resident records reviewed: 3
Number of staff records reviewed: 0
Number of resident interviews: 1
Number of staff interviews: 3
Inspection Report
Monitoring
Census: 86
Deficiencies: 2
Aug 12, 2024
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with regulations, including a self-report received regarding allegations in the area of safe, secure environment and resident care and related services.
Findings
The inspection found violations related to failure to ensure individualized service plans included identified needs based on assessments and failure to provide adequate supervision to prevent falls and wandering, supported by record reviews and staff interviews.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the individualized service plan (ISP) included a description of identified needs based on assessments, specifically for a resident with serious cognitive impairment and supervision needs. |
| Facility failed to provide adequate supervision of resident schedules, care, and activities, including prevention of falls and wandering, resulting in a resident fall with injury. |
Report Facts
Number of residents present: 86
Number of resident records reviewed: 1
Number of staff interviews conducted: 5
Incident date: Aug 7, 2024
Inspection Report
Renewal
Census: 83
Deficiencies: 10
Jul 16, 2024
Visit Reason
An unannounced renewal inspection was conducted on July 16 and July 18, 2024, to evaluate the facility's compliance with applicable standards and licensing requirements.
Findings
The inspection identified multiple violations related to admission physical examinations, Uniform Assessment Instrument completion, preliminary plans of care, hospice care coordination, resident observation and documentation, rehabilitative services, medication storage, medical procedure documentation, hazardous materials storage, and elevator inspection compliance.
Deficiencies (10)
| Description |
|---|
| Facility failed to ensure a physical examination was completed within 30 days preceding admission for resident #8. |
| Facility failed to ensure the Uniform Assessment Instrument (UAI) was completed prior to admission and upon significant changes for residents #3 and #7. |
| Facility failed to develop a preliminary plan of care on or within 7 days prior to admission for resident #3. |
| Facility failed to communicate and coordinate hospice care services in the individualized service plan (ISP) for resident #7. |
| Facility failed to regularly observe resident #3 for changes in condition and document corresponding actions, including treatment of skin tears. |
| Facility failed to arrange for specialized rehabilitative services and document completion for resident #1. |
| Facility failed to ensure medication carts were stored locked and secured; observed unlocked medication cart in safe secure unit. |
| Facility failed to ensure medical procedures or treatments ordered by a physician were provided and documented for resident #2. |
| Facility failed to store cleaning supplies and hazardous materials in a locked area; observed bleach, Comet, and cleaning liquids in unlocked medication room. |
| Facility failed to ensure elevators were inspected annually; elevator certificate of inspection expired 05/31/24. |
Report Facts
Number of residents present: 83
Number of resident records reviewed: 10
Number of staff records reviewed: 6
Number of resident interviews: 4
Number of staff interviews: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Current inspector conducting the inspection |
| Staff #7 | Staff interviewed regarding resident #3's skin tear treatment and documentation | |
| Staff #8 | Staff confirmed elevator inspection certificate expiration |
Inspection Report
Monitoring
Census: 88
Deficiencies: 5
Jun 11, 2024
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection found multiple violations related to staff qualifications, tuberculosis risk assessments, first aid certification, preliminary plans of care for residents, and emergency plan reviews. The facility was determined to be non-compliant with applicable standards and laws.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure direct care staff met required qualifications within two months of employment. |
| Facility failed to ensure each staff person submitted a tuberculosis risk assessment within 30 days prior to first day of work. |
| Facility failed to ensure each direct care staff member maintained current certification in first aid. |
| Facility failed to ensure a preliminary plan of care was developed on or within 7 days of admission for residents. |
| Facility failed to ensure procedures in the plan for resident emergencies were reviewed by staff at least every six months with signed documentation. |
Report Facts
Number of residents present: 88
Number of resident records reviewed: 6
Number of staff records reviewed: 5
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 4
Dates to be corrected: Jul 1, 2024
Dates to be corrected: Dec 31, 2024
Inspection Report
Monitoring
Census: 85
Deficiencies: 2
May 7, 2024
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with regulations, including a self-report received regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with standards related to medication management and administration. Violations were issued for failure to implement a written medication management plan and failure to administer medications according to physician orders.
Deficiencies (2)
| Description |
|---|
| Facility failed to implement a written plan for medication management to ensure timely filling and refilling of prescriptions and proper disposal of medication. |
| Facility failed to ensure medications were administered in accordance with physician's instructions, resulting in a medication error where a resident did not receive prescribed Levothyroxine and was given a discharged medication instead. |
Report Facts
Number of residents present: 85
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 2
May 7, 2024
Visit Reason
An unannounced complaint inspection was conducted due to multiple complaints received regarding Staffing and Supervision, Resident Care and Related Services, and Buildings and Grounds.
Findings
The investigation supported some, but not all, allegations of non-compliance specifically in Resident Care and Related Services. Violations were found related to medication administration timing and signaling device functionality.
Complaint Details
The complaint was received on multiple dates in April and May 2024 regarding Staffing and Supervision, Resident Care and Related Services, and Buildings and Grounds. The evidence supported some non-compliance in Resident Care and Related Services.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medications were administered within one hour before or after the scheduled dosing time, except for drugs ordered for specific times. |
| Facility failed to ensure a signaling device that terminates at a continuously staffed central location was working, preventing staff from determining the origin of signals. |
Report Facts
Residents present: 85
Resident records reviewed: 4
Staff interviews conducted: 3
Resident interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the complaint investigation |
| Maintenance Director | Completed pendant check on all resident pendants to ensure proper functioning after signaling device failure |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 1
May 7, 2024
Visit Reason
An unannounced complaint inspection was conducted due to multiple complaints received regarding staffing and supervision and resident care and related services.
Findings
The investigation supported some of the allegations related to resident care and related services, specifically failure to provide prompt response to resident call bells, resulting in neglect of resident needs. A violation notice was issued.
Complaint Details
Complaint related: Yes. Complaints received on 3/12/24, 3/13/24, 3/19/24, and 3/20/24 regarding staffing and supervision and resident care. Evidence showed neglect of resident #1 who was found on the floor after prolonged wait times for call bell response. Resident #2 also experienced delayed call bell responses. The complaint was substantiated in part.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure care provision and service delivery was resident centered and include prompt response by staff to resident needs, as evidenced by delayed responses to resident call bells. |
Report Facts
Residents present: 85
Resident records reviewed: 5
Staff records reviewed: 0
Resident interviews conducted: 3
Staff interviews conducted: 2
Call bell wait times: 6
Call bell wait times: 1
Plan of correction timeframe: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 2
Mar 7, 2024
Visit Reason
An unannounced complaint inspection was conducted due to allegations received on 2024-02-15 regarding staffing and supervision, and resident care and related services.
Findings
The investigation supported some but not all allegations, identifying non-compliance in staffing plans and medication administration timing. A violation notice was issued with opportunities for the licensee to submit a plan of correction.
Complaint Details
Complaint was received by VDSS Division of Licensing on 2024-02-15 regarding staffing and supervision, and resident care and related services. The evidence supported some allegations but not all.
Deficiencies (2)
| Description |
|---|
| Facility failed to maintain a written plan specifying the number of direct care staff required to meet day-to-day and special resident care needs. |
| Facility failed to ensure medications were administered within one hour before or after the scheduled dosing times, except for specific ordered times. |
Report Facts
Number of residents present: 84
Number of resident records reviewed: 4
Number of staff records reviewed: 0
Number of resident interviews conducted: 2
Number of staff interviews conducted: 4
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 10
Feb 6, 2024
Visit Reason
An unannounced complaint inspection was conducted due to a complaint received on 2024-01-24 regarding allegations in the areas of Personnel, Staffing and Supervision, and Resident Care and Related Services.
Findings
The investigation supported some but not all allegations, identifying multiple areas of non-compliance including failure to follow emergency procedures, inadequate staff qualifications and certifications, improper medication storage, incomplete resident service plans, and failure to maintain updated emergency plans and staff training.
Complaint Details
The complaint investigation was substantiated in part, with violations found related to personnel, staffing, supervision, and resident care. Some allegations were not supported. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.
Deficiencies (10)
| Description |
|---|
| Facility failed to ensure compliance with its own policies and procedures during a resident emergency; staff left an unresponsive resident alone and stopped CPR multiple times before EMS arrival. |
| Facility failed to ensure direct care staff met qualification requirements within two months of employment. |
| Facility failed to ensure staff submitted timely tuberculosis risk assessments prior to contact with residents. |
| Facility failed to ensure direct care staff maintained current certification in first aid. |
| Facility failed to maintain a current and accurate listing of staff certifications in first aid and CPR. |
| Facility failed to update fall risk rating after a resident fall. |
| Facility failed to include identified resident needs related to CPAP and sleep apnea in the individualized service plan. |
| Facility failed to store medications in a locked and secure manner. |
| Facility failed to store cleaning supplies and hazardous materials in a locked area accessible only to staff. |
| Facility failed to ensure staff reviewed the resident emergency plan at least every six months with documentation. |
Report Facts
Number of residents present: 84
Number of resident records reviewed: 8
Number of staff records reviewed: 7
Number of resident interviews conducted: 2
Number of staff interviews conducted: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #4 | Named in findings related to failure to follow emergency procedures, lack of current first aid certification, and failure to review emergency plan. | |
| Staff #9 | Named in findings related to failure to follow emergency procedures and failure to review emergency plan. | |
| Staff #7 | Named in findings related to lack of documentation of direct care qualifications, tuberculosis risk assessment, and first aid certification. | |
| Staff #8 | Acknowledged missing documentation for other staff regarding training and certifications. | |
| Staff #6 | Named in finding related to lack of first aid certification documentation. | |
| Staff #2 | Named in findings related to missing tuberculosis risk assessment. | |
| Staff #5 | Named in finding related to failure to review emergency plan. |
Inspection Report
Renewal
Census: 84
Deficiencies: 10
Jan 3, 2024
Visit Reason
An unannounced renewal inspection was conducted on January 3 and 4, 2024, to assess compliance with applicable standards and licensing requirements for the assisted living facility.
Findings
The inspection identified multiple violations related to resident assessments, staff training, tuberculosis risk assessments, physical examinations, sex offender screenings, preliminary plans of care, resident rights reviews, fire inspection documentation, and first aid kit completeness. The facility was found non-compliant with several regulatory standards and was issued a violation notice.
Deficiencies (10)
| Description |
|---|
| Failed to ensure residents with serious cognitive impairment were assessed by a licensed clinical psychologist or physician prior to admission. |
| Failed to ensure staff training commenced within 60 days of employment. |
| Failed to ensure staff submitted tuberculosis risk assessments within required timeframe prior to contact with residents. |
| Failed to ensure physical examinations and tuberculosis risk assessments were completed within 30 days preceding admission and properly signed by physicians. |
| Failed to ascertain and document whether potential residents were registered sex offenders prior to admission within three days. |
| Failed to complete Uniform Assessment Instrument (UAI) prior to admission and annually. |
| Failed to develop preliminary plans of care on or within 7 days of admission. |
| Failed to review and document residents' rights and responsibilities annually with written acknowledgement. |
| Failed to maintain documentation of annual fire inspection after January 6, 2022. |
| Failed to maintain a complete first aid kit with required items and unexpired supplies. |
Report Facts
Number of residents present: 84
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of resident interviews: 4
Number of staff interviews: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the renewal inspection |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 1
Jan 3, 2024
Visit Reason
An unannounced complaint inspection was conducted due to allegations received regarding Staffing and Supervision, and Resident Care and Related Services.
Findings
The investigation supported some, but not all, of the allegations related to Resident Care and Related Services. A violation notice was issued for medication administration timing violations.
Complaint Details
Complaint related: Yes. The complaint was regarding Staffing and Supervision, and Resident Care and Related Services. Evidence supported non-compliance in Resident Care and Related Services.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered within one hour before or after the scheduled dosing times, except for drugs ordered for specific times. |
Report Facts
Residents present: 84
Resident records reviewed: 10
Staff records reviewed: 5
Resident interviews: 4
Staff interviews: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Conducted the inspection and medication pass observation |
Inspection Report
Renewal
Census: 84
Deficiencies: 9
Jan 10, 2023
Visit Reason
An unannounced renewal inspection was conducted on January 10 and January 12, 2023, to assess compliance with applicable standards and licensing requirements for the assisted living facility.
Findings
The inspection identified multiple areas of non-compliance including expired staff licenses, incomplete tuberculosis risk assessments, failure to complete required assessments upon resident condition changes, missing signatures on service plans, lack of dietitian oversight for special diets, unlicensed medication administration, insufficient fire and emergency drill documentation, and employment of a staff member with barrier crimes. Plans of correction were proposed for each deficiency.
Deficiencies (9)
| Description |
|---|
| Staff #1 had an expired certified nursing aide license but was providing direct care. |
| Facility failed to ensure annual tuberculosis risk assessments were completed for each resident. |
| Uniform Assessment Instrument (UAI) was not completed following significant changes in resident conditions. |
| Individualized Service Plans (ISP) updates lacked required signatures and dates from licensee, administrator, or resident/legal representative. |
| Dietitian oversight of special diets was not conducted at least every six months as required. |
| Staff administering medications were not licensed or registered as required; Staff #1's medication aide license was expired. |
| Fire and emergency evacuation drills were not conducted on each shift at least quarterly as required. |
| No evidence of staff participation in resident emergency procedure exercises every six months. |
| Employment of Staff #4 who had convictions for two barrier crimes, making them ineligible for employment. |
Report Facts
Residents present: 84
Resident records reviewed: 10
Staff records reviewed: 5
Resident interviews: 4
Staff interviews: 4
Residents on special diets: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Named in findings for expired CNA license and expired medication aide license while providing direct care and administering medications | |
| Staff #3 | Acknowledged lack of awareness of Staff #1's expired CNA license and lack of documentation for fire and emergency drills and resident emergency exercises | |
| Staff #4 | Named in finding for having convictions for two barrier crimes making them ineligible for employment; employee terminated | |
| Donesia Peoples | Licensing Inspector | Conducted the inspection |
| Business Office Manager | Responsible for implementing tickler system to ensure licenses are current and reviewing new hires for barrier crimes | |
| Healthcare Director | Responsible for ensuring TB screenings, ISP updates, and license checks | |
| Executive Director | Responsible for ensuring ISP updates, dietary oversight, fire drills, emergency trainings, and new hire screenings | |
| Dining Service Director | Responsible for ensuring dietary oversight reports | |
| Maintenance Director | Responsible for fire drills and resident emergency trainings |
Inspection Report
Renewal
Census: 81
Deficiencies: 17
Dec 17, 2021
Visit Reason
An unannounced renewal inspection was conducted on December 17 and December 20, 2021, to assess compliance with regulatory standards for the assisted living facility.
Findings
The inspection identified multiple deficiencies including incomplete cognitive impairment training for staff, missing documentation such as TB screenings and job descriptions, unlabeled resident glucometers, outdated first aid/CPR postings, incomplete staff schedules, inadequate infection control procedures, and fire safety documentation deficiencies. Plans of correction were provided for each deficiency with due dates in early 2022.
Deficiencies (17)
| Description |
|---|
| Direct care staff did not complete required 10 hours of cognitive impairment training within four months of employment. |
| Non-nursing staff did not complete 2 hours of cognitive impairment training within the first month of employment. |
| Residents' glucometers were not labeled. |
| Staff person did not have documentation of receiving a copy of current job description. |
| Staff records lacked documentation of tuberculosis risk assessment prior to employment. |
| First aid and CPR listing posted was not up to date and did not include all staff names. |
| Written work schedules did not include full names, job classifications, or indicate person in charge. |
| Facility failed to post the name of the current on-site person in charge in a conspicuous place. |
| Resident records lacked annual tuberculosis risk assessment documentation. |
| Annual reassessment using Uniformed Assessment Instrument (UAI) was not current for some residents. |
| Individualized service plans (ISP) did not address all assessed resident needs or were not updated annually. |
| Medication orders for PRN medications did not include exact dosage instructions. |
| Hot water temperature in resident areas exceeded the required range of 105-120 degrees Fahrenheit. |
| Facility building was not maintained in good repair and cleanliness; vent covered with grayish substance. |
| Facility failed to comply with Virginia Statewide Fire Prevention Code; last fire inspection was outdated. |
| Fire and emergency evacuation drawings posted did not include all required information such as telephone locations and fire alarm boxes. |
| Fire drill records lacked required documentation including number of residents, special conditions simulated, and problems encountered. |
Report Facts
Facility census: 81
Training hours required: 10
Training hours required: 2
Water temperature: 125.8
Fire drill dates missing documentation: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Inspector | Current inspector conducting the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 9, 2021
Visit Reason
A non-mandated self-report inspection was initiated due to a self-reported incident regarding allegations in resident care and related services, specifically concerning supervision and safety of a resident with exit-seeking behavior.
Findings
The investigation confirmed non-compliance with supervision standards, as resident #1 exited the secure unit multiple times and was found outside the facility in the community, posing safety risks. Violations were issued related to failure to provide adequate supervision and prevent wandering.
Complaint Details
The visit was complaint-related based on a self-reported incident. The evidence supported the self-report of non-compliance with standards. Resident #1 was discharged from the community following the incident.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure supervision of resident schedules, care, and activities, including prevention of falls and wandering from the premises. |
Report Facts
Inspection dates: 4
Distance resident found from facility (miles): 1.06
Speed limit (mph): 45
Inspection Report
Monitoring
Census: 57
Deficiencies: 0
Jun 14, 2021
Visit Reason
A monitoring inspection was initiated and conducted using an alternate remote protocol due to a state of emergency health pandemic declared by the Governor of Virginia.
Findings
The inspection reviewed resident records, training logs, and medication observation documentation and determined no violations with applicable standards or law. No violations were issued.
Inspection Report
Complaint Investigation
Deficiencies: 4
Mar 2, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding Special Care Unit requirements at the facility. The investigation was conducted remotely due to a state of emergency health pandemic.
Findings
The investigation supported allegations of non-compliance with standards, including failure to secure harmful materials from residents and deficiencies in individualized service plans, medication management, and unauthorized release of resident information. Violations were issued based on these findings.
Complaint Details
The complaint investigation was initiated based on allegations related to Special Care Unit requirements. The evidence supported the allegations, and violations were issued. The complaint was substantiated.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure ordinary materials that may be harmful to a resident are inaccessible except under staff supervision, evidenced by unlocked drawers with mouthwash, toothpaste, and shampoo in resident bathrooms. |
| Facility failed to ensure the Individualized Service Plan (ISP) included the resident's identified need, date identified, and expected outcome date. |
| Facility released information regarding a resident's personal affairs without written permission of the resident or legal representative. |
| Facility failed to implement its written plan for medication management ensuring each resident's medications are refilled in a timely manner, resulting in missed medication administrations. |
Report Facts
Inspection dates: Inspection conducted on March 2 and March 3, 2021
Medication administration dates missed: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Inspector | Conducted the inspection and investigation |
| Staff #1 | Confirmed resident behaviors and acknowledged broken locks and medication management issues | |
| Staff #2 | Acknowledged deficiencies in individualized service plans and medication management | |
| Healthcare Director | Completed training on leave of absence protocol and medication administration processes | |
| Executive Director | Contacted by telephone to conduct investigation and responsible for corrective actions |
Inspection Report
Renewal
Census: 52
Deficiencies: 3
Jan 6, 2021
Visit Reason
A renewal inspection was initiated on January 6, 2021 and concluded on January 12, 2021 to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including failure to keep harmful materials inaccessible to residents with serious cognitive impairments, improper medication administration not following prescriber instructions, and incomplete documentation of fire and emergency evacuation drills.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that ordinary materials or objects that may be harmful to a resident with a serious cognitive impairment are inaccessible except under staff supervision. |
| Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions. |
| Facility failed to ensure a record of the required fire and emergency evacuation drills included the number of residents participating, special conditions simulated, time to complete the drill, and weather conditions. |
Report Facts
Medication administrations not held per instructions: 46
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Inspector | Current Inspector conducting the inspection. |
| Staff #1 | Provided incident report and acknowledged medication administration and fire drill documentation issues. |
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