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Every family's needs are unique. We encourage you to visit Harmony on the Peninsula 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.
Families often praise the facility for its beautiful, clean environment and the kindness of specific caregivers and dining staff. However, there are serious allegations regarding management instability, high staff turnover in memory care, and instances of neglect regarding hygiene and communication.
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Key Review Excerpts
“The memory care unit has a high staff turnover, with little to no accountability for the lack of proper resident care. My relative was frequently left unclean, smelling strongly of urine, and often dressed in clothing that wasn’t hers.”
“The facility looks clean and well-decorated. But the problems run deep, stemming from leadership that turned over by 100% in our 1.5 years there, and became more disorganized and disconnected with each new director.”
Source: VA State Licensing Agency
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: 7/2/2025 10:45 am- 4:37 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 6/24/2025 regarding allegations in the area(s) of: Personnel The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 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 a self-report submitted to the licensing office as well as staff interviews, the facility failed to ensure that all staff shall be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged or infirm or who have disabilities. Evidence: 1. The facility submitted a self-report on 6/24/2025, which indicated an agitated and aggressive resident was being redirected by Staff # 2 when the resident hit the staff member in the face. Staff # 2 in turn hit the resident on the side of the head and stated, ?now you can see what it feels like.? 2. The facility suspended Staff # 2 while an investigation was conducted. The facility also reported the incident to the local Adult Protective Services. 3. A statement from Staff # 3 who witnessed the incident stated that Staff # 2 was walking with the resident to the activity room, the resident punched the staff member in the face. Staff # 2 then punched the resident on the head 3-4 times. 4. A statement from Staff # 4 indicated that Resident # 1 was aggressive and hit/punched Staff # 2 who in turn hit the resident in the face several times. 5. Staff # 2 was terminated by the facility.
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: 7/2/25 10:45 am- 4:37 pm, 8/1/25 10:00 am- 11:00 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 1/8/2025 regarding allegations in the area(s) of: Resident Care and Related Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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: 0 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. However, violation(s) not related to the (complaint(s)/self-report) but identified during the course of the investigation can 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 the record reviewed, the facility failed to ensure that a fall risk assessment was reviewed and updated after every fall. Evidence: The Progress Notes for Resident #1 documented a fall which occurred 12/29/24. There was no fall risk assessment for 12/29/24 provided to the Licensing Inspector for the associated fall.
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: 7/2/25 10:45am-4:37 pm, 7/24/25 8:53 am- 9:32 am, 8/1/2025 10:00 am- 11:00 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 1/8/2025 regarding allegations in the area(s) of: Resident Care and Related Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 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 resident record reviewed and staff interviewed, the facility failed to ensure in accordance with 63.2-1805 D Code of Virginia, it did not admit or retain individuals with any prohibitive conditions without required documentation. Evidence: 1. Resident # 5 has been prescribed Clonazepam 0.5 mg for agitation. There was no psychotropic treatment plan for the medication in the resident?s chart that was provided to the Licensing Inspector at the time of the inspection. 2. Staff #2 acknowledged there was no psychotropic treatment plan for the medication in the resident?s file.
Based on record review and staff interview, the facility failed to ensure individualized service plans ( ISP
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. During the on-site inspection on 7/24/2025, the Licensing Inspector conducted medication observation passes with Staff #3. Resident # 3 was prescribed a Lidocaine 4% path which was to be applied in the morning 10:00 am and removed at night 9:00 pm. Staff # 3 begin to apply the Lidocaine patch when Resident # 3 stated the Lidocaine patch from the previous day had not been removed. The resident then showed Staff # 3 the patch, which was then removed. The Licensing Inspector asked Staff # 3 if the observed Lidocaine patch from 7/23/25 should have been removed the previous evening and the staff member stated yes, it should have been removed during the nighttime medication pass. 2. The 7/23/25 medication administration record, for Resident # 3 was initialed to indicate that the patch had been removed on the previous night.
Based on a review of resident records and staff interview, the facility failed to ensure complete Uniform Assessment Instruments ( UAI
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: 7/2/2025 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 10/9/2024 regarding allegations in the area(s) of: Resident Care and Related Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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 the review of facility records and interviews conducted the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with bathing - at least twice a week, but more often if needed or desired. Evidence: 1. The Licensing Inspector reviewed shower logs and skin assessments for residents in the safe secure unit for the month of June 2025. The shower logs were incomplete. 2. Staff # 2 acknowledged the shower logs and skin assessment documentation was incomplete and inconsistent for residents in the safe secure.
Based on a review of resident records, the facility failed to ensure for each resident with an inability to use the signaling device, to document the rounds that were made, including the time of the rounds. Evidence: 1. The Licensing Division received a complaint regarding rounds not being conducted for individuals who have an inability to use the signaling device. 2. The Licensing Inspector reviewed the rounding sheet for the month of June 2025, for the residents in the Safe, Secure Unit. The individuals on the unit have an inability to use the signaling device. The rounding sheets did not document staff conducted rounds consistently every two hours for any of the residents in the safe, secure unit. 3. Staff #2 acknowledged the rounds for residents in the safe, secure unit were not consistently and accurately documented.
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: 3/17/2025 9:30 am- 1:30 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: 65 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: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: The Licensing Inspector conducted an inspection of memory care rooms, observed several activities being conducted. The inspector also observed lunch being served. 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 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: On 3/17/2025, during the on-site with the audit of the controlled medication books, the Controlled Medication Count Records for Medication Cart #3 had omissions for 3/12/2025, Medication Cart #5 had an omission for 3/17/2025, Medication Cart #4 had omissions for 3/12/2025 and 3/15/2025.
Based on observation, the facility failed to ensure medications to 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 Administrator Audit Report for March 1, 2025, through March 17, 2025, for Residents #1 and # 2, documented the residents? physician prescribed medications were administered late every day during the time reviewed. There was no documentation on the residents? MAR
Type of inspection: Monitoring ?self-report Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/23/2024 9:00am- 3:30pm 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: 77 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: 3 Number of interviews conducted with staff: 4 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 observation, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident with a serious cognitive impairment, these materials or objects shall be in accessible to the resident except under staff supervision. Evidence: 1. During the on-site inspection of the safe, secure unit, the Licensing Inspector observed Hydrogen Peroxide, Preparation H ointment, Medicated hemorrhoid pads with witch hazel (picture attached). 2. Staff #3 acknowledged the items should not have been accessible to the resident.
Based on staff interview and resident record review, the facility failed to provide supervision of the resident schedule and specialized needs. Evidence: 1. Resident # 1 was diagnosed with a cognitive impairment of dementia which is chronic and progressive based upon a statement written by their nurse practitioner on 7/1/2023. The statement further states the resident requires assistance with all of her activities of daily living, and she is unable to make any decisions regarding person, financial, or healthcare matters. 2. The UAI
Based on a review of resident records, the facility failed to ensure for each resident with an inability to use the signaling device, to document the rounds that were made, including the time of the rounds. Evidence: 1. The Licensing Inspector inspected and reviewed the facility?s Call System Round Log Sheets for the months of August and September 2024 for residents #1 and #2. 2. The rounding sheets for Resident #1 did not document rounding was complete every two hours per the facility policy on the following days: 8/24/24, 8/27/24, 8/28/24, 8/29/24, 8/30/24, 8/31/24, 9/1/24, 9/2/24, 9/3/24, 9/4/24, 9/5/24, 9/6/24, 9/7/24, 9/9/24, 9/10/24, 9/11/24, and 9/12/24. 3. The Call System Round Log Sheets for Resident # 2 for the month of August 2024 could not be located per Staff #3. 4. The rounding sheets for Resident #2 did not document rounds were complete every two hours per the facility policy on the following days: 9/2/24, 9/6/24, 9/10/24, 9/11/24, and 9/12/24.
Based on record reviewed the facility failed to ensure the personal and social information document was kept current. Evidence: The Social Data information for Resident # 1 was not updated as the Social Data form stated the resident was a Full Code however the resident had a DNR.
Based on observation and staff interviewed, the facility failed to ensure the interior of the building was maintained in good repair and kept clean and free of rubbish. Evidence: 1. During the 9/23/24 on-site inspection the following items were observed by the licensing inspector: A. Ceiling leak in the front conference room (picture attached). B. Wall behind resident apartment door in the memory care unit (picture attached). 2. Staff #1 acknowledged the ceiling in the conference room was in need of repair. 3. Staff #3 acknowledged the wall behind the resident entrance door was in need of repair.
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: 9/23/2024, 11/19/2024 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: 77 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 record reviewed, the facility failed to ensure that a fall risk assessment was reviewed and updated after every fall. Evidence: 1. Resident # 2 had a documented fall on 6/3/24 and there was no fall risk assessment in the resident record provided at the time of the inspection. 2. Resident # 5 had a documented fall on 10/2/24 and there was no fall risk assessment in the resident record provided at the time of the inspection.
Based on review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. Evidence: Based on review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. Evidence: 1. The record for Resident #3 (D.O.A. 3/18/24) contained a sex offender verification dated 4/16/24. 2. The record for Resident #1 (D.O.A. 2/15/23) contained a sex offender verification dated 3/1/23.
Based on a review of staff records, the facility failed to verify that each staff person has received a copy of his or her current job description. Evidence: 1. The Staff files for Staff #3 and #7 did not contain a signed job descriptions. 2. Staff #3 acknowledged the files did not contain signed job descriptions.
Based on a review of staff records, the facility failed to ensure each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment. Evidence: 1. Direct Staff member # 6 (D.O.H. 2/8/24) did not contain documentation of current First Aid certification as of the date of the file review on the inspection on 11/19/24. 2. Staff # 3 acknowledged that Staff member # 6 did not have current First Aid certification.
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan ( ISP
Based on records reviewed and staff interviewed, the facility failed to ensure the individualized service plan ( ISP
Based on record review, it was determined that the facility did not ensure that prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the written approval following order of priority. Evidence: 1. Resident # 3 was placed in the safe, secure unit on 3/8/24 as documented on the Resident?s Social Data form. 2. A written approval form dated 9/19/24 was found in the record for Resident #3. 3. Staff #1 was unable to provide documentation that written approval prior to placement following the order of priority was obtained.
Based on records reviewed and staff interviewed, the facility failed to ensure a documented interview between the administrator or designee responsible for admission and retention, between the individual, and the legal representative, if any was in the record for a resident. Evidence: The records for Resident # 4 (D.O.A. 4/4/24) and Resident # 2 (D.O.A. 2/8/24) did not include documentation an interview occurred.
Based on record reviewed and staff interviewed, the facility failed to ensure the record included an acknowledgement of the resident having received an orientation and the acknowledgment signed and dated by the resident, and as appropriate legal representative and kept in the resident?s record. Evidence: Resident #1 and #3?s records did not include documentation of an orientation for new residents which included information regarding mealtimes, the use of the call system, and the emergency response procedures.
Based on record reviewed and staff interviewed, the facility failed to ensure the record included an acknowledgement of the resident having received an orientation and the acknowledgment signed and dated by the resident, and as appropriate legal representative and kept in the resident?s record. Evidence: Resident #1 and #3?s records did not include documentation of an orientation for new residents which included information regarding mealtimes, the use of the call system, and the emergency response procedures.
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: 9/23/24 9:00 am- 3:35 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaints were received by VDSS Division of Licensing on 2/7/24 and 2/16/24 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 77 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was 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 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 August and September 2024 documented staff failed to ensure counts of all controlled substances occurred between oncoming staff and off going staff.
Based on observation, 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 February 1, 2024, through February 29, 2024, for Resident #1 documented the resident received over 388 doses of medication later than the standard dosing schedule.
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. The Division received a complaint regarding medication not being administered as prescribed. 2. Resident # 1 was prescribed Humira 40 mg/0.8 ml by syringe every other week for rheumatoid arthritis. 3. A review of the February 2024 Medication Administration Record verified Resident # 1 did not receive the prescribed Humira 40 mg/0.8 ml doses on 2/15/24 and 2/29/24. 4. Staff #1 acknowledged the resident did not receive the prescribed medication in accordance with the prescriber?s order.
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Harpers Station Yorktown
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2.0 miNursing Home · Newport News, VA
Newport News Baptist Retirement Community DBA the Chesapeake
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Regency Health and Rehabilitation Center
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