Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 0
Jul 1, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-02-28 regarding allegations in the areas of Resident Care and Related Services and Buildings 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 and a copy is required to be posted at the facility.
Complaint Details
Complaint received on 2025-02-28 regarding Resident Care and Related Services and Buildings and Grounds. The allegations were not substantiated by the investigation.
Report Facts
Resident records reviewed: 2
Staff records reviewed: 0
Interviews conducted with residents: 0
Interviews conducted with staff: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Conducted the inspection and is the contact for questions |
Inspection Report
Monitoring
Census: 86
Deficiencies: 0
Jul 1, 2025
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review resident care and related services at the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. The inspector reviewed training for RMAs, medication carts, self-monitoring tools for medication administration, refills, and narcotic inventory management.
Report Facts
Number of residents present: 86
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: 3
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Jan 13, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-12-05 regarding allegations in the areas of staffing 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. No deficiencies were cited.
Complaint Details
Complaint investigation related to allegations of staffing and resident care; the allegations were not substantiated.
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Jan 13, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-12-05 regarding allegations in the areas of staffing 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. An exit meeting will be conducted to review the inspection findings.
Complaint Details
Complaint related to staffing and resident care and related services; the allegations were not substantiated.
Report Facts
Number of residents present: 78
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
Renewal
Census: 78
Deficiencies: 4
Jan 13, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and laws.
Findings
The inspection found non-compliance with applicable standards and laws, resulting in documented violations related to individualized service plans and medication management practices.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure the individualized service plan (ISP) included all required elements, specifically missing outcome dates for identified needs. |
| Facility failed to follow medication management plan ensuring prescriptions and over-the-counter drugs were filled and refilled timely to avoid missed dosages. |
| Facility failed to implement its written plan for medication management regarding accurate counts of controlled substances during staff changes. |
| Facility failed to ensure medications were administered no earlier than one hour before and no later than one hour after the standard dosing schedule. |
Report Facts
Residents present: 78
Resident records reviewed: 5
Staff records reviewed: 3
Resident interviews conducted: 2
Staff interviews conducted: 3
Missed medication doses: 4
Months narcotic inventory counts failed: 3
Late medication administrations: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Inspector conducting the renewal inspection |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 1
Jul 19, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-06-11 regarding allegations related to Resident Care and Related Services at the facility.
Findings
The investigation found non-compliance with medication administration standards, specifically that medications were not administered according to physician or prescriber instructions. Violations were issued based on evidence including medication counts, pharmacy verification, and interviews with facility staff.
Complaint Details
The complaint was substantiated based on evidence including family member reports, medication card pill counts, pharmacy verification, and staff interviews indicating medication administration inconsistencies for Resident #1.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions. |
Report Facts
Number of residents present: 61
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Medication pill counts: 5
Medication pill counts: 4
Medication pill counts: 4
Medication pill counts: 4
Medication pill counts: 14
Medication pill counts: 6
Medication pill counts: 7
Medication pill counts: 12
Medication pill counts: 5
Medication pill counts: 8
Medication pill counts: 10
Documented medication refusal days: 3
Medication supply duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Conducted inspection and investigation, interviewed facility director |
| Harmony Square Director | Interviewed regarding medication administration inconsistencies |
Inspection Report
Monitoring
Census: 60
Deficiencies: 8
May 30, 2024
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 failure to obtain timely criminal history reports for employees, lack of first aid certification for direct care staff, inaccurate posting of the on-site person in charge, incomplete discharge statements, discrepancies in individualized service plans, medication management deficiencies including missed dosages and incomplete controlled substance counts, and failure to post the most recent inspection findings.
Deficiencies (8)
| Description |
|---|
| Failed to obtain the criminal history record report on or prior to the 30th day of employment for an employee. |
| Failed to ensure that each direct care staff member without current first aid certification received certification within 60 days of employment. |
| Failed to ensure the posting of the name of the current on-site person in charge was accurate. |
| Failed to ensure that a discharge statement included all required information at time of discharge. |
| Failed to ensure each resident's individualized service plan contained a description of all needs/services identified. |
| Failed to implement written plan for medication management to ensure timely filling and refilling of prescriptions to avoid missed dosages. |
| Failed to ensure accurate counts of all controlled substances whenever assigned medication staff changes. |
| Failed to post the findings of the most recent inspection of the facility. |
Report Facts
Number of residents present: 60
Number of resident records reviewed: 6
Number of staff records reviewed: 4
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 4
Days medication doses missed: 11
Days controlled medication counts missing: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Inspector conducting the monitoring visit |
| Staff #1 | Acknowledged missing criminal history record report and discharge statement | |
| Staff #4 | Employee without criminal history record report and first aid certification | |
| Staff members 2, 3, and 5 | Acknowledged incomplete controlled medication count records | |
| ED | Executive Director responsible for corrective actions including updating postings and ensuring compliance | |
| BOM | Board of Management involved in corrective actions | |
| HCD | Health Care Director involved in auditing and corrective actions | |
| HSD | Health Services Director involved in auditing and corrective actions |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Apr 27, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-04-24 regarding allegations related to Resident Care and Related Services.
Findings
The investigation found non-compliance with standards related to medication management, specifically the failure to implement the facility's written plan to ensure timely filling and refilling of residents' medications, resulting in missed blood sugar checks for a resident.
Complaint Details
The complaint was substantiated as the evidence supported the allegation of non-compliance with standards related to medication management.
Deficiencies (1)
| Description |
|---|
| Facility failed to implement its written plan for medication management to ensure timely filling and refilling of medications, leading to missed dosages. |
Report Facts
Residents present: 83
Resident records reviewed: 3
Staff interviews conducted: 2
Missed blood sugar checks: 29
Inspection Report
Monitoring
Census: 83
Deficiencies: 15
Apr 27, 2023
Visit Reason
The inspection was a monitoring visit conducted on April 27, 2023 and May 5, 2023 to review compliance with applicable regulations and standards for an assisted living facility.
Findings
The inspection identified multiple violations related to resident safety, staff documentation, medication management, and care planning. Deficiencies included unsecured hazardous materials, missing clinical assessments, incomplete staff records, lack of posted manager information, incomplete resident assessments and service plans, failure to document showers, missing menus, and medication order issues.
Deficiencies (15)
| Description |
|---|
| Facility failed to ensure hazardous materials were inaccessible to residents with serious cognitive impairment; kitchen door was propped open with detergent within reach. |
| Residents admitted to safe, secure unit lacked required assessments by independent clinical psychologist or physician. |
| Staff records lacked documentation of signed job descriptions. |
| Direct care staff did not maintain current certification in first aid. |
| Facility failed to post the name of the current on-site person in charge. |
| Facility admitted or retained individuals with prohibitive conditions without required documentation, including missing psychotropic treatment plans. |
| Residents lacked required physical examinations and tuberculosis risk assessments within 30 days prior to admission. |
| Facility failed to ensure annual tuberculosis risk assessments were completed for residents. |
| Uniform assessment instruments (UAIs) were not completed annually as required. |
| Comprehensive individualized service plans (ISPs) were not completed within 30 days after admission. |
| Individualized service plans (ISPs) were not updated annually or as needed for significant changes in resident condition. |
| Facility failed to provide personal assistance and care including bathing at least twice a week as necessary. |
| Facility failed to post the weekly menu for the current week. |
| Facility failed to implement medication management plan ensuring accurate counts of controlled substances during staff changes. |
| Medications and treatments were started or changed without valid signed physician orders. |
Report Facts
Number of residents present: 83
Number of resident records reviewed: 9
Number of staff records reviewed: 6
Number of resident interviews: 3
Number of staff interviews: 6
Controlled medication count failures: 22
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 6
Mar 1, 2023
Visit Reason
The inspection was conducted in response to several complaints received by VDSS Division of Licensing regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the allegations of non-compliance with standards and laws, resulting in violations issued. Deficiencies included inadequate staffing during night hours, missing signatures on assessment and service plan documents, failure to indicate meal time needs, late medication administration, and failure to conduct proper documented rounds in memory care.
Complaint Details
Several complaints (#568987 & #568900) were received on 1/5/2023, 1/23/2023, and 2/20/2023 regarding Resident Care and Related Services. The evidence supported the allegations and violations were issued.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure at least three direct care staff members were awake and on duty during night hours when 23 to 32 residents were present in the special care unit. |
| Uniform assessment instrument (UAI) forms were not approved and signed by the administrator or designee. |
| Individualized Service Plan (ISP) was not signed by the resident or legal representative. |
| ISP did not indicate the approximate amount of time needed for meals for a resident assessed as dependent in eating/feeding. |
| Medication was administered late beyond the facility's standard dosing schedule for multiple residents. |
| Two hour documented rounds in memory care were not conducted properly; rounds were documented at the exact same time for all residents. |
Report Facts
Residents present: 27
Resident records reviewed: 6
Staff interviews conducted: 5
Resident interviews conducted: 2
Medication late administration days for Resident #4: 26
Medication late administration days for Resident #4: 11
Medication late administration days for Resident #5: 16
Medication late administration days for Resident #5: 6
Medication late administration days for Resident #6: 27
Medication late administration days for Resident #6: 12
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 4
Mar 1, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-01-05 regarding allegations related to personnel, buildings and grounds, and activities at the facility.
Findings
The investigation supported the allegations of non-compliance with multiple standards, resulting in violations issued related to administrator coverage lapse, failure to post the on-site person in charge, poor maintenance and cleanliness of the building, and strong odors in the secure unit.
Complaint Details
Complaint #56897 was received by VDSS Division of Licensing on 2023-01-05 regarding personnel, buildings and grounds, and activities. The evidence gathered supported the allegations and violations were issued.
Deficiencies (4)
| Description |
|---|
| Facility failed to immediately employ a new administrator or appoint a qualified acting administrator, resulting in a lapse in administrator coverage. |
| Facility failed to implement a procedure for posting the name of the current on-site person in charge in a conspicuous place. |
| Facility failed to maintain the interior and exterior of the building in good repair, including stained carpet and furniture in the safe secure unit. |
| Facility failed to have the building well ventilated and free from foul, stale, and musty odors; strong urine odor detected in the secure unit. |
Report Facts
Number of residents present: 27
Number of resident interviews: 2
Number of staff interviews: 5
Inspection time: 4
Inspection Report
Renewal
Census: 90
Deficiencies: 0
Dec 16, 2021
Visit Reason
An unannounced renewal inspection was conducted to evaluate compliance with licensing requirements and regulations for the assisted living facility.
Findings
The inspection included a tour of the facility, review of records, observation of activities and medication passes, and verification of required postings. No violations were cited during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 2, 2021
Visit Reason
A non-mandated complaint inspection was initiated due to allegations in the areas of Personnel, Administration and Administrative Services, and Resident Care and Related Services.
Findings
The investigation did not support the allegation of non-compliance with standards or law related to the complaint. However, a violation was found regarding failure to immediately notify residents' contact persons or legal representatives of suspected abuse.
Complaint Details
The complaint was related to allegations of name calling and abuse towards residents. The evidence gathered did not substantiate the complaint, but a violation was identified regarding delayed notification to residents' contacts about suspected abuse.
Deficiencies (1)
| Description |
|---|
| Facility failed to notify the resident's contact person or legal representative immediately when a report of suspected abuse was made relating to the resident. |
Report Facts
Inspection dates: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Inspector | Named as the current inspector conducting the investigation |
| Staff #1 | Provided evidence and acknowledged failure to notify residents' contacts immediately |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 10, 2021
Visit Reason
A complaint inspection was initiated due to a complaint received by the department regarding allegations in the area of Resident Rights.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint related to Resident Rights; investigation concluded with no substantiation of allegations.
Inspection Report
Renewal
Census: 68
Deficiencies: 1
Nov 6, 2020
Visit Reason
A renewal inspection was initiated on November 6, 2020 and concluded on December 2, 2020 to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliances related to medication administration, specifically that medications were not administered in accordance with physician's instructions and standards of practice.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications are administered in accordance with the physician's instructions and consistent with standards of practice. |
Report Facts
Inspection dates: 5
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