Inspection Reports for
Culpepper Garden III, INC
4439 N. Pershing Drive, ARLINGTON, VA, 22203
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
57 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Renewal
Census: 57
Deficiencies: 5
Date: Aug 26, 2025
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection found multiple violations including failure to ensure direct care staff met employment requirements, incomplete individualized service plans, confidentiality breaches with resident records, medication administration errors, and inadequate medication error documentation.
Deficiencies (5)
Facility failed to ensure direct care staff meet employment requirements within two months if not met at time of hire.
Facility failed to ensure individualized service plan (ISP) is updated annually or as needed to accurately reflect resident care needs and services.
Facility failed to ensure all records are treated confidentially; observed unattended resident health information on medication cart.
Facility failed to ensure medications were administered according to physician's instructions; medication error observed during eye drop administration.
Facility failed to ensure medication administration records (MAR) included documentation of medication errors or omissions.
Report Facts
Residents present: 57
Resident records reviewed: 6
Staff records reviewed: 3
Resident interviews conducted: 1
Staff interviews conducted: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 3 | Named in deficiency related to failure to meet direct care staff employment requirements | |
| Staff 1 | Confirmed Staff 3's lack of required documentation and confirmed ISP and MAR deficiencies | |
| Staff 4 | Involved in medication administration error with Resident 5 |
Inspection Report
Monitoring
Census: 58
Deficiencies: 0
Date: Jul 22, 2025
Visit Reason
The inspection was conducted as a monitoring visit following a complaint received on 2025-01-13 regarding allegations in the area of Quality of Care.
Complaint Details
A complaint was received by VDSS Division of Licensing on 2025-01-13 regarding Quality of Care. The evidence gathered did not support the allegation(s) of non-compliance.
Findings
The investigation did not support the allegations of non-compliance with standards or law. Observations included residents engaging in activities and no deficiencies were noted in the report.
Report Facts
Residents present: 58
Resident records reviewed: 3
Staff records reviewed: 2
Resident interviews conducted: 3
Staff interviews conducted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Licensing Inspector | Named as the current inspector conducting the inspection |
Inspection Report
Monitoring
Census: 101
Deficiencies: 0
Date: May 8, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with various regulatory provisions and standards at the assisted living facility.
Findings
The licensing inspector completed a tour of the physical plant and conducted interviews and record reviews. Observations noted residents engaging in the common area. The investigation did not support any self-reported non-compliance with standards or laws.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Census: 101
Deficiencies: 3
Date: Mar 24, 2025
Visit Reason
The inspection was a monitoring visit conducted to assess compliance with applicable standards and laws at the assisted living facility Culpepper Garden III, INC.
Findings
The inspection found non-compliance with several standards related to security monitoring for residents with serious cognitive impairments, staffing plans aligned with resident acuity, and supervision of residents to prevent wandering or elopement. Violations were documented and a plan of correction was requested.
Deficiencies (3)
Facility failed to ensure doors leading outside have a system of security monitoring for residents with serious cognitive impairments.
Facility failed to have a written staffing plan specifying number and type of direct care staff related to resident acuity levels.
Facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering.
Report Facts
Number of residents present: 101
Number of resident records reviewed: 3
Number of staff records reviewed: 3
Number of staff interviews conducted: 3
Incident time: 1033
Incident secured time: 1056
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Licensing Inspector | Named as the current inspector conducting the inspection and contact for questions |
| Staff 1 | Staff member interviewed who confirmed lack of active monitoring of security systems and staffing plan issues |
Inspection Report
Renewal
Census: 65
Deficiencies: 7
Date: Aug 6, 2024
Visit Reason
The inspection was a renewal inspection conducted on August 6-7, 2024, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations including failure to update individualized service plans timely, improper posting of resident rights, failure to document oversight of special diets, unsigned physician orders within required timeframes, unsecured hazardous materials, and lack of documentation for emergency preparedness plan reviews.
Deficiencies (7)
Facility failed to ensure individualized service plans are reviewed and updated at least once every 12 months and as needed for significant changes.
Facility failed to ensure the Rights and Responsibilities of Residents are posted in a conspicuous place with correct contact information.
Facility failed to ensure that action taken in response to oversight of special diets is documented in the resident's record.
Facility failed to ensure physician's or other prescriber's oral orders are reviewed and signed within 14 days.
Facility failed to ensure cleaning supplies and other hazardous materials are stored in a locked area.
Facility failed to ensure semi-annual review on the emergency preparedness and response plan for all staff and residents.
Facility failed to ensure the annual emergency preparedness plan review was documented by signing and dating the plan.
Report Facts
Number of residents present: 65
Number of resident records reviewed: 3
Number of staff records reviewed: 3
Number of interviews with residents: 1
Number of interviews with staff: 2
Inspection Report
Renewal
Census: 69
Deficiencies: 2
Date: Sep 14, 2023
Visit Reason
The inspection was conducted as a renewal inspection to review compliance with regulatory standards and assess facility operations.
Findings
The inspection identified two violations: the facility failed to have a staff record on site as required, and there was a lack of a coordinated plan of care between the hospice agency and the facility on the Individualized Service Plan for a resident receiving hospice services.
Deficiencies (2)
Facility failed to have a staff record at the facility as required.
Facility failed to have a coordinated plan of care between the hospice agency and the facility on the Individualized Service Plan.
Report Facts
Census: 69
Records reviewed: 9
Interviews conducted: 7
Inspection Report
Monitoring
Census: 72
Deficiencies: 0
Date: Jul 14, 2023
Visit Reason
The inspection was a focused monitoring visit to ensure correction of a previous B-2 violation cited during an inspection on 2023-03-14.
Findings
The inspection found no violations with applicable standards or laws. The evidence gathered determined compliance with regulations.
Report Facts
Resident records reviewed: 6
Staff records reviewed: 0
Interviews with residents: 0
Interviews with staff: 2
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
Date: Jul 14, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-07-10 regarding allegations in the area(s) of admission, retention, and discharge of residents.
Complaint Details
Complaint related to admission, retention, and discharge of residents; investigation found no substantiation of non-compliance.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of receipt.
Report Facts
Number of residents present: 72
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: 2
Inspection Report
Monitoring
Census: 70
Deficiencies: 1
Date: Mar 14, 2023
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 non-compliance related to medication administration, specifically a failure to ensure medications were administered according to physician orders and approved standards. A violation notice was issued to the facility.
Deficiencies (1)
Facility failed to ensure medications were administered in accordance with physician's instructions and approved medication aide curriculum standards, evidenced by incorrect medication administration timing for Resident #1.
Report Facts
Number of residents present: 70
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #5 | Named in medication administration observation related to deficiency |
Inspection Report
Renewal
Census: 71
Deficiencies: 1
Date: Oct 5, 2021
Visit Reason
A renewal inspection was initiated on 09/30/2021 and concluded on 10/05/2021 to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified non-compliance related to the failure to obtain criminal history record reports on or prior to the 30th day of employment for each employee, specifically for Staff 4. A violation notice was issued and a plan of correction was required.
Deficiencies (1)
The facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee.
Report Facts
Staff hire date: Mar 29, 2021
Criminal history record date: Aug 26, 2021
Census: 71
Inspection Report
Monitoring
Deficiencies: 0
Date: May 12, 2021
Visit Reason
A monitoring inspection was initiated due to a self-reported incident regarding allegations in the areas of personnel. The administrator was contacted to conduct the investigation.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. Any violations not related to the self-report but identified during the investigation can be found on the violation notice.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 19, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding buildings and grounds conditions, specifically pest infestations, at the facility.
Complaint Details
The complaint was substantiated based on evidence gathered during the investigation regarding pest infestations in Resident #1's apartment.
Findings
The investigation confirmed non-compliance with standards related to pest infestations in Resident #1's apartment, with documented evidence of cockroach activity and treatment. Additional violations not related to the complaint were also identified.
Deficiencies (1)
Facility failed to ensure that buildings shall be kept free of infestations of insects.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Inspector | Named as the current inspector conducting the complaint investigation. |
| Staff #1 | Notified about pest infestation and involved in communication and investigation. | |
| Resident #1's daughter | Reported pest infestation and provided photographic evidence. | |
| Assisted Living Administrator | Conducted inspections and coordinated pest control and staff training. | |
| Director of Plant Operations | Participated in inspections, pest control coordination, and staff training. |
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