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Every family's needs are unique. We encourage you to visit Harmony at Oakbrooke in person, speak with staff and current residents' families, and trust your instincts. The data on this page provides a starting point, but your personal impression matters most.
Harmony at Oakbrooke is highly regarded by many families for its compassionate staff, beautiful facilities, and successful transitions into memory care. While many reviewers praise the warm atmosphere and professional leadership, some families have reported serious concerns regarding medication management, frequent falls, and communication breakdowns during medical emergencies.
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Key Review Excerpts
“My dad's birthday was recent, and we brought in a huge cake to share. The staff worked the magic to have everyone sing Happy Birthday. To watch the residents, sing and enjoy a slice of cake was priceless and heartfelt.”
“He started in independent living and when he started having more severe issues as his dementia progressed, the staff noticed and suggested memory care. We were heartbroken and scared of what this transition would look like, but the director Jennifer and the other staff were so helpful.”
“The team within Harmony Oakboroke saved a life in our family, I am certain of this.”
Source: VA State Licensing Agency
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/29/2025 8:30 am- 4:25 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Based on the record reviewed, the facility failed to ensure that a fall risk assessment was reviewed and updated after a resident experience a fall. Evidence: 1. Resident #6 had documented falls on 11/1/2024 and 11/27/2024. There were no fall risk assessments for the associated falls. 2. Staff # 5 and Staff # 6 acknowledged there were no fall risk assessments for the falls.
Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes. Evidence: 1. A review of the Controlled Substances/Inventory Log for the months of November 2025 and December 2025 documented staff failed to ensure counts of all controlled substances occurred between oncoming staff and off going staff for medication carts in the memory care and assisted living units. 2. Staff #3 acknowledged the Change of Shift-Controlled Medication Count Sheet was not completed for each change of shift.
Based on the on-site record review and staff interview the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually. (Exception: Direct care staff who are licensed health care professions or certified nurse aides shall attend at least 12 hours of annual training). Evidence: 1. During the review of staff records, the record for Staff # 1 (date of hire 12/6/2021) did not contain documentation of the required number of training hours for a direct care staff. 2. Staff #7 acknowledged the staff training records for Staff # 1 were not available for the inspector to review.
Based on the record review the facility failed to ensure an assisted living facility shall comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: 1. The facility's last recorded annual fire inspection was 11/6/2024. 2. Staff #7 acknowledged the facility's last annual fire inspection was 11/6/2024.
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/1/2025 11:15 am- 11:45 am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 2/28/2025 regarding allegations in the area(s) of: Resident Care and Related Services and Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/1/2025 10:15 am- 11:10 am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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 Observations by licensing inspector: Licensing Inspector inspected training for RMAs, inspected medication carts on both the memory care and assisted living units, the facility?s self-monitoring tools regarding medication administration, medication refills, and management of narcotic inventory. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/13/2025 (9:06 am ? 1:52 pm) and 1/ 30/2025 (10:40 am- 12:40 pm) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/5/2024 regarding allegations in the area(s) of: Staffing Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 78 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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 Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/13/2025 (9:06 am ? 1:52 pm) and 1/ 30/2025 (10:40 am- 12:40 pm) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/5/2024 regarding allegations in the area(s) of: Staffing Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 78 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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 Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/13/2025 (9:06 am- 1:52 pm), 1/30/2025 10:40 am- 12:40 pm) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 78 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Based on resident record review, the facility failed to follow their medication management plan in regard to ensuring each resident?s prescription medication and any over the counter drugs for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: The medication administration record for January 2025, for Resident # 5 notated the resident?s Buspirone 10 mg was not available to be administered on 1/6/2025 (am dose), 1/12/2025 (am and pm doses), and 1/13/2025 (am dose).
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan ( ISP
Based on record review, the facility failed to ensure medications be administered no earlier than one hour before and no later than one hour after the facility?s standard dosing schedule, except for those drugs that are ordered for specific times. Evidence: A review of the Medication Administration Audit Report for January 1, 2025, through January 13, 2025, for residents #3, #4, and #5 documented the residents received medication late on 1/1/2025, 1/11/2025, and 1/13/2025.
Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes. Evidence: A review of the Narcotic Inventory Count Verification forms for the months of November 2024, December 2024 and January 2025 documented staff failed to ensure counts of all controlled substances occurred between oncoming staff and off going staff.
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/19/2024 9:30 am ? 1:30 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 6/11/2024regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Based on a review of facility records, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. Licensing Inspector received a complaint from a family member regarding medication not being administered to Resident #1 as prescribed by the physician. The family member sent pictures of unadministered medication they received back from the staff at the end of the month. The family member confirmed the resident had been at the facility every day for the time period the medications should have been administered. The pictures submitted to the Licensing Inspector documented the following medications and number of pills remaining on the medication cards: Leflunomide 10 mg (prescribed-1 pill to be administered in the morning for RA) 5 pills on the morning medication card which originally contained 31 pills Preservision (prescribed for eye health) 4 pills remaining on the morning medication card which originally contained 31 pills Vitamin D3 (prescribed as a supplement) 4 pills remaining on the morning medication card which originally contained 31 pills Metoprolol Succ ER 50 mg (prescribed for blood pressure) 4 pills remaining on the morning medication card which originally contained had 31 pills Olmesartan Medoxomil 40 mg (prescribed for high blood pressure) 14 pills remaining on the morning medication card which originally contained had 31 pills Clopidogrel 75 mg (prescribed for transient ischemic attack -TIA) 6 pills remaining on the medication card which had 31 pills which originally contained had 31 pills Citalopram 10 mg (prescribed for mood) 7 pills remaining on the medication card which originally contained had 31 pills Creon DR 36,000 units (prescribed for IBS) 12 pills remaining on the medication card which had 31 pills 2. On 7/19/2024, during the on-site inspection, the Licensing Inspection conducted an inspection of the medication cart. The Licensing Inspector reviewed the following medications and pills remaining in the medication cards: Colestipol HCL 1GM- (prescribed for IBS) there were 5 pills remaining on the card which originally contained had 31 pills Colestipol HCL 1GM- (prescribed for IBS) there were 8 pills remaining on the card which originally contained 30 pills Divaloprex 250 mg- (prescribed for mood stabilization)- there were 10 pills remaining on the card which originally contained 30 pills 3. The Licensing Inspector reviewed the Medication Administration Record for the month July 2024. There were only documented 3 days the resident either refused or was unavailable to take medication. 4. The Pharmacy Review provided to the Licensing Inspector for July 2024, did not have Resident # 1 listed as frequently refusing medications. 5. The Licensing Inspection interviewed the Harmony Square Director regarding the inconsistencies in the medication count on the medication cards. The Harmony Square Director was unable to explain why the pills administ
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/30/2024 8:10 am- 2:30 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 60 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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 Observations by licensing inspector: Licensing inspector observed activities being conducted, a meal, and medication passes. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia E. Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes. Evidence: 1. A review of the Controlled Medication Count Record for the medication carts on the 2nd and 3rd floors for the month of May 2024 documented staff failed to ensure counts of all controlled substances were documented on 31 out of 31 days reviewed. 2. Staff members 2,3, and 5 all acknowledged the Controlled Medication Count Records were incomplete.
Based on review of resident record, the facility failed to ensure that a discharge statement included all the required information listed in the standards to be provided to the resident and as appropriate, his legal representative and designated contact person at the time of discharge. Evidence: 1. The file for Resident #1 did not contain a discharge statement. 2. Staff #1 acknowledged the file did not contain a discharge statement.
Based on observation, the facility failed to ensure the posting of the name of the current on-site person in charge. Evidence: On the date of the inspection 5/30/2024, the posting of the on-site person in charge was not accurately updated to reflect the person who was in charge of the building at the time the inspector entered the building.
Based on staff record review, the facility failed to obtain the criminal history record report on or prior to the 30th day of employment for an employee. Evidence: 1. During the inspection conducted on 5/30/224, a record review indicated the date of hire for Staff #4 was 12/19/2023. The staff?s record did not contain a completed criminal history record report. 2. Staff #1 acknowledged the record did not contain a criminal history record report.
Based on a review of resident records the facility failed to ensure that each resident's individualized service plan ( ISP
Based on record review, the facility failed to implement its written plan for medication management, specifically regarding methods to ensure that each resident?s prescription medications and over-the counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: 1. The facility?s Medication Management Plan states that, ?Nurses and RMA?s shall be responsible for the timely ordering, and re-ordering of medications so that there are no missed doses or interruptions in the medications being administered.? The policy further states, ?If a medication is not available to administer for any reason, the nurse/RMA will contact the physician to inform of when the medication will be made available and seek further instruction. The physician?s instructions will be documented on the (E) MAR
Based on observation, the center failed to post the findings of the most recent inspection of the facility. Evidence: During an inspection of the center on 5/30/2024, the findings of the most recent inspection of the center were not observed to be posted.
Based on a review of staff records the facility failed to ensure that each direct care staff member who did not have current certification in first aid shall receive certification in first aid within 60 days of employment. Evidence: The employee file for Staff #4 (D.O.H) 12/19/2023 did not contain evidence of the staff member having First Aid certification.
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