Inspection Reports for Arleigh Burke Pavilion at Vinson Hall Retirement Community
VA, 22101
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
42% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
19 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Monitoring
Census: 19
Deficiencies: 0
Date: Jun 10, 2025
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 found no violations with applicable standards or laws. The licensing inspector completed a tour of the physical plant, reviewed resident records, conducted interviews, and observed facility activities.
Report Facts
Number of resident records reviewed: 2
Number of resident interviews conducted: 3
Number of staff interviews conducted: 2
Inspection Report
Monitoring
Deficiencies: 0
Date: May 21, 2025
Visit Reason
The inspection was a monitoring visit focused on administration and administrative services at the assisted living facility.
Findings
Facility documentation was reviewed and one staff interview was conducted. No violations were cited during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Jan 15, 2025
Visit Reason
The inspection was conducted based on complaints and concerns regarding failure to provide timely discharge notifications, bed hold notices, baseline care plan summaries, implementation of care plans, medication administration per physician orders, respiratory care, and monitoring of anticoagulant medications.
Complaint Details
The visit was complaint-related, triggered by allegations of failure to provide discharge notifications, bed hold notices, baseline care plan summaries, proper care plan implementation, medication administration errors, inadequate respiratory care, and lack of anticoagulant monitoring. Substantiation status is not explicitly stated.
Findings
The facility failed to provide written discharge notifications and bed hold notices for Resident #15, failed to provide baseline care plan summaries for Residents #35 and #36, failed to implement care plans for Residents #42 and #18, failed to provide proper respiratory care for Resident #141, and failed to monitor anticoagulant therapy for Residents #3, #6, #11, #18, and #22. Multiple interviews and record reviews confirmed these deficiencies with minimal harm or potential for harm to residents.
Deficiencies (9)
Failed to provide written notification of discharge reasons to Resident #15.
Failed to provide bed hold notice at discharge for Resident #15.
Failed to provide baseline care plan summaries for Residents #35 and #36.
Failed to implement comprehensive care plan for Residents #42 and #18.
Failed to position Resident #42 in proper body alignment.
Failed to provide restorative nursing/maintenance services for Resident #42.
Failed to provide respiratory care in a sanitary manner for Resident #141 by not storing incentive spirometer properly.
Administered Amlodipine outside physician-ordered parameters for Resident #18 multiple times.
Failed to monitor anticoagulant therapy as ordered for Residents #3, #6, #11, #18, and #22.
Report Facts
Residents in survey sample: 25
Dates of medication administration outside parameters: 10
Medication dosage: 5
Anticoagulant dosage: 2.5
Anticoagulant dosage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Interviewed regarding failure to provide written discharge notification and baseline care plan summaries. | |
| OSM #1 (Social Services Manager) | Interviewed regarding discharge notification responsibilities. | |
| ASM #1 (Administrator) | Informed of multiple concerns including discharge notification, bed hold notices, care plan implementation, and medication administration. | |
| ASM #2 (Director of Nursing) | Informed of multiple concerns including discharge notification, bed hold notices, care plan implementation, and medication administration. | |
| ASM #4 (Senior Director of Clinical Services) | Informed of multiple concerns and provided statements regarding restorative care and anticoagulation monitoring. | |
| ASM #5 (Chief Operating Officer) | Informed of multiple concerns. | |
| LPN #1 | Interviewed regarding anticoagulant monitoring and medication administration. | |
| OSM #3 (Physical Therapist) | Interviewed regarding Resident #42 positioning and therapy recommendations. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jan 15, 2025
Visit Reason
The inspection was conducted due to concerns about medication administration and monitoring, specifically regarding the use of unnecessary medications and failure to monitor anticoagulant therapy as ordered for several residents.
Complaint Details
The visit was complaint-related, triggered by concerns about medication administration and monitoring. The complaint was substantiated based on staff interviews, clinical record reviews, and facility document reviews indicating failure to monitor anticoagulant therapy and administration of medication outside ordered parameters.
Findings
The facility staff failed to ensure residents were free from unnecessary medications by not adhering to physician-ordered parameters for medication administration and failing to monitor anticoagulant therapy for five residents (R3, R6, R11, R22, and R18). Interviews and record reviews revealed lack of proper documentation and monitoring of anticoagulation, despite facility policies requiring such monitoring.
Deficiencies (5)
Facility staff administered Amlodipine outside of physician-ordered blood pressure parameters for Resident #18 multiple times.
Facility staff failed to monitor anticoagulant therapy as ordered for Resident #3.
Facility staff failed to monitor anticoagulant therapy as ordered for Resident #6.
Facility staff failed to monitor anticoagulant therapy as ordered for Resident #11.
Facility staff failed to monitor anticoagulant therapy as ordered for Resident #22.
Report Facts
Residents in survey sample: 25
Residents affected: 5
BIMS score: 13
BIMS score: 3
BIMS score: 15
BIMS score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Interviewed about medication administration and blood pressure parameters | |
| ASM #1 | Administrator informed of concerns | |
| ASM #2 | Director of Nursing informed of concerns | |
| ASM #3 | Senior Director Clinical Services informed of concerns | |
| ASM #4 | Senior Director Clinical Services interviewed about anticoagulation monitoring | |
| ASM #5 | Chief Operating Officer informed of concerns | |
| LPN #1 | Interviewed about anticoagulant monitoring and documentation |
Inspection Report
Renewal
Census: 18
Deficiencies: 0
Date: Jul 24, 2023
Visit Reason
The inspection was conducted as a renewal inspection to review compliance with regulations and assess the facility's operations since the last inspection.
Findings
The inspection included review of six records and three interviews, observation of residents during lunch and activities, and evaluation of various administrative and resident care areas. All facility self-reported incidents since the last inspection were reviewed.
Report Facts
Records reviewed: 6
Interviews conducted: 3
Inspection Report
Monitoring
Census: 18
Deficiencies: 0
Date: May 31, 2023
Visit Reason
The inspection was a monitoring visit to review various areas including administration, personnel, staffing, resident care, building and grounds, emergency preparedness, and background checks for the assisted living facility.
Findings
The inspection included review of 8 records and 5 interviews, observation of residents eating lunch, and medication administration. All facility self-reported incidents since the last inspection were reviewed.
Report Facts
Records reviewed: 8
Interviews conducted: 5
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 11, 2022
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide timely written notification to the resident's responsible party and Ombudsman upon hospital transfer, and failure to evidence a current dialysis contract with an outside dialysis center for residents.
Complaint Details
The complaint investigation revealed that the facility did not provide written notification to the resident's responsible party and Ombudsman after a hospital transfer on 6/23/22. The facility policy did not require written notification to the Ombudsman. Additionally, the facility lacked a current dialysis contract with the outpatient dialysis center for Resident #33.
Findings
The facility failed to provide written notification to the resident's responsible party and Ombudsman for a hospital transfer of Resident #16 on 6/23/22, and the facility policy did not require written notification to the Ombudsman. Additionally, the facility failed to evidence a current dialysis contract with the outpatient dialysis center providing services to Resident #33.
Deficiencies (2)
Failure to provide timely written notification to the resident's responsible party and Ombudsman before transfer or discharge, including appeal rights, for Resident #16.
Failure to evidence a current dialysis contract between the facility and the outpatient dialysis center providing services for Resident #33.
Report Facts
Residents in survey sample: 23
Date of hospital transfer: Jun 23, 2022
Date of survey completion: Aug 11, 2022
Assessment Reference Date: Jul 25, 2022
Assessment Reference Date: Jul 9, 2022
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ASM #1, Director of Nursing and Acting Administrator | Stated no documentation of written notices and was aware of dialysis contract issue | |
| OSM #1, Social Services Manager | Stated no written notification provided to responsible party for hospital transfers and Ombudsman only notified for discharges to home or other long term care |
Inspection Report
Monitoring
Census: 20
Deficiencies: 1
Date: May 25, 2022
Visit Reason
The inspection was a monitoring visit to review compliance with regulations, including administration, personnel, resident care, and emergency preparedness.
Findings
The facility was found deficient for failing to have comprehensive Individualized Service Plans (ISPs) for residents, specifically lacking documentation addressing hospice care, bedside rails, and home health therapies for three residents.
Deficiencies (1)
Facility failed to have a comprehensive Individualized Service Plan (ISP) for residents in care, lacking documentation for hospice care, bedside rails, and home health therapies.
Report Facts
Number of resident records reviewed: 3
Number of staff records reviewed: 3
Number of interviews conducted: 4
Number of comprehensive ISPs to be audited monthly: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Inspector | Current Inspector conducting the monitoring inspection |
| Director of Nursing | Responsible for ensuring correction of ISP deficiencies |
Inspection Report
Routine
Deficiencies: 3
Date: Jul 7, 2021
Visit Reason
The inspection was conducted as a routine survey to assess compliance with federal and state regulations regarding resident privacy, food safety, infection control, and sanitation practices.
Findings
The facility was found deficient in maintaining resident privacy during blood pressure checks, proper food storage and dishwashing temperatures in the kitchen, and infection control practices including hand hygiene and disinfection of reusable blood pressure cuffs between residents.
Deficiencies (3)
Failed to provide privacy for two residents when obtaining blood pressure readings in the dining room.
Failed to store and prepare foods in a sanitary manner; food items were not labeled with opening dates and dishwashing machine rinse temperatures were below required levels.
Failed to maintain infection control practices by not washing hands or using sanitizer and not disinfecting reusable blood pressure cuffs between residents.
Report Facts
Residents in survey sample: 23
Residents affected by privacy deficiency: 2
Residents affected by infection control deficiency: 4
Dishwashing machine temperature runs observed: 5
Dishwashing machine temperature out of range dates: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in privacy and infection control deficiencies related to blood pressure readings |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding cleaning and disinfection procedures for blood pressure cuffs |
| OSM #3 | Director of Dining Services | Interviewed regarding food storage and dishwashing temperature monitoring |
| OSM #4 | Dietary Aide | Observed operating dishwashing machine and unaware of temperature monitoring procedures |
| ASM #1 | Administrator | Made aware of findings during inspection |
| ASM #2 | Director of Nursing | Made aware of findings during inspection |
Inspection Report
Renewal
Census: 19
Deficiencies: 1
Date: Jun 1, 2021
Visit Reason
A renewal inspection was initiated on June 1, 2021 and concluded on June 2, 2021 to assess compliance with applicable standards and licensing requirements for the assisted living facility.
Findings
The inspection identified non-compliance with standards related to individualized service plans, specifically the failure to document the need, service, and responsible provider for PT/OT services in a resident's plan. Violations were documented and a plan of correction was required.
Deficiencies (1)
Facility failed to ensure that the comprehensive individualized service plan included a written description of what services will be provided to address identified needs, and who will provide them.
Report Facts
Census: 19
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