Inspection Reports for Greenbrier Assisted Living
8204 Madrillon Estates Dr, Vienna, VA 22182, United States, VA, 22182
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Inspection Report
Renewal
Census: 7
Deficiencies: 48
Aug 27, 2025
Visit Reason
The inspection was a renewal inspection conducted over three days: August 27, 2025, September 4, 2025, and September 5, 2025, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations including inadequate staffing levels, failure to secure windows and medications, poor infection control practices, lack of proper documentation and record keeping, medication management deficiencies, unsafe physical environment conditions, and failure to treat residents with dignity and respect. Numerous repeated violations from prior inspections were noted.
Deficiencies (48)
| Description |
|---|
| Failed to ensure at least two direct care staff awake and on duty at all times in each building responsible for care and supervision. |
| Failed to ensure protective devices on bedroom and bathroom windows to prevent residents from crawling through. |
| Ordinary materials or objects harmful to residents with serious cognitive impairment were accessible without staff supervision. |
| Failed to implement infection control program addressing surveillance, prevention and control of disease and infection. |
| Failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license. |
| Failed to maintain records, reports, plans, schedules, and allow reasonable opportunity for inspection and interviews. |
| Failed to submit written reports of incidents to licensing office within seven days. |
| Administrator failed to be responsible for general administration and management of the facility. |
| Failed to ensure administrators supervising medication aides completed required training. |
| Failed to ensure direct care staff completed approved personal care aide training program. |
| Failed to ensure all direct care staff attend at least 18 hours of training annually. |
| Failed to retain staff records confidentially and in locked area with emergency contact information accessible. |
| Failed to maintain personal and social data in staff records as required. |
| Failed to maintain health information including TB risk assessments in staff records. |
| Failed to post a listing of all staff with current certification in first aid or CPR. |
| Failed to maintain a written work schedule for all staff including absences, substitutions or changes. |
| Failed to post the name of the current on-site person in charge accurately and timely. |
| Failed to secure medical attention immediately for serious illness and notify physician within 24 hours. |
| Failed to document identification of specific residents for whom health care oversight was provided. |
| Failed to ensure staff or volunteers lead and assist residents during activities. |
| Failed to ensure visiting hours were not restricted except by resident choice. |
| Failed to post rights and responsibilities of residents conspicuously in the facility. |
| Failed to ensure menus for meals and snacks were dated and posted conspicuously. |
| Failed to provide or access a current diet manual for food preparation staff. |
| Failed to implement written medication management plan and ensure medications were available and properly stored. |
| Failed to ensure no medication, diet, or treatment started, changed, or discontinued without valid physician order. |
| Failed to ensure residents' records contained signed or dated physician orders organized chronologically. |
| Failed to obtain new medication orders upon resident's return from hospital and notify primary physician. |
| Failed to ensure medication storage areas and controlled substances were properly secured and keys kept on person. |
| Failed to ensure medications were removed from pharmacy containers and administered by authorized staff. |
| Failed to administer medications within one hour before or after scheduled dosing times. |
| Failed to administer medications in accordance with physician or prescriber instructions. |
| Failed to label over-the-counter medications with resident's name or in pharmacy-issued container. |
| Failed to ensure PRN medications ordered were available for administration. |
| Used physical restraints without physician order and resident consent; bedrails used as restraints. |
| Failed to develop and implement policy for missing resident personal possessions. |
| Failed to ensure bedrooms had window coverings for privacy. |
| Failed to ensure at least one operable telephone was easily accessible to staff. |
| Failed to ensure residents with serious cognitive impairment did not have access to hazardous cleaning supplies. |
| Failed to maintain interior and exterior of buildings in good repair and free of rubbish. |
| Failed to maintain furnishings, fixtures, and equipment in good repair and condition. |
| Failed to ensure all steps, stairways, and ramps have nonslip surfaces. |
| Failed to ensure elevators were inspected annually and certificate provided. |
| Failed to ensure toilets and bathing facilities were separated by gender as required. |
| Failed to develop a written emergency preparedness and response plan including annual contact with local emergency coordinator. |
| Failed to ensure a complete first aid kit was on hand with required supplies. |
| Failed to obtain criminal history record report on or prior to 30th day of employment for staff. |
| Failed to treat residents with courtesy, respect, and dignity during medication administration. |
Report Facts
Number of residents present: 7
Number of resident records reviewed: 2
Number of staff records reviewed: 3
Number of resident interviews: 6
Number of staff interviews: 5
Number of violations in prior inspections: 36
Number of violations in recent inspections: 21
Medication administration observation duration: 75
Number of medications administered late: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Licensing Inspector | Current inspector conducting the inspection |
| Staff 3 | Registered Medication Aide | Named in multiple medication administration and supervision violations |
| Staff 4 | Staff person in charge | Named in medication administration and staffing violations |
| Staff 5 | Facility Administrator | Named in administration and management violations |
Inspection Report
Complaint Investigation
Census: 6
Deficiencies: 0
Jul 29, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-07-03 regarding allegations in the area of health related services.
Findings
The investigation did not support the allegation(s) of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant and conducted interviews with residents and staff.
Complaint Details
Complaint related to health related services; evidence gathered did not support the allegations of non-compliance.
Report Facts
Residents present: 6
Resident records reviewed: 2
Staff records reviewed: 0
Resident interviews conducted: 2
Staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 6
Deficiencies: 17
Jul 29, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on July 29, 2025, regarding allegations in the areas of physical plant, medication/medical issues, emotional abuse/neglect, physical abuse/neglect, records, and admissions/discharge.
Findings
The investigation supported some but not all allegations, identifying areas of non-compliance in physical plant, medication/medical issues, emotional abuse/neglect, records, and admissions/discharge. Multiple violations were cited related to staff scheduling, resident records, medication administration, facility safety, and resident rights.
Complaint Details
The complaint investigation was substantiated in part, with evidence supporting some allegations related to physical plant, medication/medical issues, emotional abuse/neglect, records, and admissions/discharge. Some allegations were not supported.
Deficiencies (17)
| Description |
|---|
| Facility failed to maintain a written work schedule including names, job classifications, and indication of who is in charge each shift. |
| Facility failed to ensure all resident personal and social information was obtained prior to or at time of admission. |
| Resident agreement did not include all required provisions and did not accurately reflect resident's current room. |
| Uniform assessment instrument (UAI) was not updated to reflect significant changes in resident's condition. |
| Facility failed to ensure UAI was completed by a qualified assessor with state-approved training. |
| Individualized service plans were not reviewed and updated at least annually or as needed for significant changes. |
| Facility failed to ensure health care service needs of residents were met, including consistent nutritional supplement administration. |
| Facility lacked a contractual agreement with a licensed nurse or home health agency for skilled nursing treatments required by resident. |
| Door leading to outside was locked from inside with a Master U-bike lock, violating safety regulations. |
| Facility failed to have a current picture or updated physical description of resident for identification. |
| Medications, dietary supplements, and treatments were started or changed without valid physician orders. |
| Medication aides were not supervised by a full-time licensed individual as required. |
| Facility failed to document all medications administered on medication administration records (MAR), including over-the-counter and dietary supplements. |
| Facility failed to provide adequate and accessible closet or wardrobe space in resident's bedroom. |
| Facility failed to obtain documentation signed by building official as evidence of compliance with Virginia Uniform Statewide Building Code for resident's room. |
| Facility failed to ensure at least one bathtub or shower on each floor with resident bedrooms. |
| Facility failed to post residents' rights and responsibilities conspicuously in the facility. |
Report Facts
Number of residents present: 6
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of interviews with residents: 1
Number of interviews with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Licensing Inspector | Inspector conducting the complaint investigation. |
| Staff 1 | Facility staff involved in multiple findings including scheduling, resident records, medication administration, and interviews. | |
| Staff 2 | Facility staff who completed the Uniform Assessment Instrument and was involved in inspection interviews. | |
| Staff 3 | Facility staff involved in observations and interviews related to door lock and medication administration. |
Inspection Report
Monitoring
Census: 7
Deficiencies: 32
Jul 9, 2024
Visit Reason
The inspection was a monitoring visit conducted on July 9, 2024, July 17, 2024, and August 27, 2024, to review compliance with applicable standards and laws for Greenbrier Assisted Living.
Findings
The inspection found multiple violations including failure to provide reasonable access to records, failure to post the current license, failure to report major incidents timely, inadequate staff training, incomplete staff records, medication management deficiencies, unsafe storage of hazardous materials, and deficiencies in emergency preparedness and facility maintenance.
Deficiencies (32)
| Description |
|---|
| Facility failed to ensure reasonable opportunity to inspect all buildings, books, records, and interview relevant persons. |
| Facility failed to post the most recently issued license in a conspicuous place. |
| Facility failed to report major incident within 24 hours to regional licensing office. |
| Facility failed to maintain written reports of incidents. |
| Direct care staff failed to attend at least 18 hours of annual training. |
| Facility failed to maintain complete personal and social data in staff records. |
| Facility failed to post listing of staff with current first aid or CPR certification. |
| Facility failed to update postings of current on-site person in charge. |
| Facility failed to establish written communication method for direct care staff. |
| Facility failed to register with Department of State Police for sex offender notifications within local zip codes. |
| Facility failed to obtain all required resident personal and social information at admission. |
| Facility failed to maintain service plans accessible to direct care staff while protecting confidentiality. |
| Facility failed to post current month's activity schedule in a conspicuous location or make it available. |
| Facility failed to ensure door leading outside was not locked or secured from inside. |
| Facility failed to post dated menus and record substitutions or additions. |
| Facility failed to provide or access a diet manual containing acceptable nutrition practices. |
| Facility failed to prevent use of outdated, damaged, or contaminated medications and ensure medication staff qualifications. |
| Facility failed to ensure resident's record contained signed physician or prescriber orders. |
| Facility failed to ensure use of secure medication storage and proper medication labeling. |
| Facility failed to ensure Do Not Resuscitate (DNR) orders were readily available to authorized persons. |
| Facility failed to ensure advance directives were readily available to authorized persons. |
| Facility failed to store cleaning supplies and hazardous materials in locked areas. |
| Facility failed to keep furnishings, fixtures, and equipment clean and in good repair. |
| Facility failed to ensure stairways had non-slip surfaces. |
| Facility failed to provide paper towels or air dryer at common face/hand washing sinks. |
| Facility failed to conduct fire and emergency evacuation drills for each shift in different months. |
| Facility failed to maintain complete records of fire and emergency evacuation drills. |
| Facility failed to maintain a complete and current first aid kit. |
| Facility failed to provide evidence of monthly first aid kit checks. |
| Facility failed to test on-site emergency generator monthly and maintain records. |
| Facility failed to post findings of the most recent inspection on premises. |
| Facility failed to obtain criminal history record report on or prior to 30th day of employment for each employee. |
Report Facts
Number of residents present: 7
Number of resident records reviewed: 6
Number of staff records reviewed: 5
Number of resident interviews: 3
Number of staff interviews: 4
Expired medications observed: 11
Training hours for Staff 4: 14
Fire drill documentation dates: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Licensing Inspector | Current inspector conducting the monitoring inspection. |
| Staff 1 | Mentioned in relation to lack of access to electronic records, failure to post updated license, and medication administration. | |
| Staff 3 | Mentioned in relation to denying access to basement, reporting incidents, medication administration, and communication failures. | |
| Staff 4 | Mentioned in relation to training hours deficiency and expired credentials. | |
| Staff 2 | Mentioned in relation to dietary services and menu posting. |
Inspection Report
Renewal
Census: 7
Deficiencies: 0
Sep 21, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the Greenbrier Assisted Living facility.
Findings
The inspection included review of administration, personnel, resident care, building and grounds, emergency preparedness, and background checks. Six records and two interviews were reviewed, and residents were observed during lunch. No complaint was related to this inspection.
Report Facts
Records reviewed: 6
Interviews conducted: 2
Inspection Report
Renewal
Census: 4
Deficiencies: 0
Dec 1, 2022
Visit Reason
An unannounced renewal inspection was conducted to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. Resident and staff records, medication administration, and background checks were reviewed with no deficiencies noted.
Report Facts
Resident census: 4
Staff present: 1
Resident records reviewed: 4
Staff records reviewed: 2
Individual interviews: 1
Inspection summary posting timeframe: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Inspector | Current inspector conducting the inspection |
| Lynette Storr | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Renewal
Census: 5
Deficiencies: 8
Apr 13, 2022
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with licensing standards and regulations for Greenbrier Assisted Living.
Findings
The inspection identified multiple areas of non-compliance related to documentation of admission physical examinations, sex offender status verification, completion of the Uniform Assessment Instrument, individualized service plans, medication administration records, storage of hazardous materials, and fire inspection documentation. Several issues were disputed by the facility as not care-related or related to records from other facilities.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure that the admission physical examination included recommendations for care including medication, diet, therapy, and ambulatory status. |
| Facility failed to ascertain and document sex offender status for residents with stays longer than three days. |
| Facility failed to ensure the Uniform Assessment Instrument (UAI) was completed as required. |
| Facility failed to ensure the comprehensive Individualized Service Plan included all identified needs and dates. |
| Facility failed to ensure completion and retention of subsequent annual reports from the Virginia Department of Health. |
| Facility failed to document symptoms for which medication was given on the Medication Administration Record (MAR). |
| Facility failed to store cleaning supplies and hazardous materials in a locked area. |
| Facility failed to provide documentation of an annual Fire Inspection as required by the Virginia Statewide Fire Prevention Code. |
Report Facts
Residents in care during inspection: 5
Staff present during inspection: 1
Resident records reviewed: 3
Staff records reviewed: 3
Individual interviews conducted: 1
Inspection Report
Complaint Investigation
Deficiencies: 10
Oct 27, 2021
Visit Reason
Unannounced complaint investigation regarding resident medication, staff qualifications, and billing practices.
Findings
The complaint was deemed valid as evidence supported allegations related to resident medication and staff qualifications. Multiple violations were identified including failure to maintain staff records, improper work schedules, incomplete assessments, and medication storage issues.
Complaint Details
The complaint was substantiated as a preponderance of evidence supported allegations regarding resident medication and staff qualifications.
Deficiencies (10)
| Description |
|---|
| Facility failed to ensure that a record shall be established for each staff person. |
| Facility failed to ensure that a written work schedule including names, job classifications, and person in charge is maintained. |
| Facility failed to ensure that the current on-site person in charge is posted. |
| Facility failed to ensure that the Uniform Assessment Instrument (UAI) is completed by trained staff. |
| Facility failed to ensure that the UAI is completed within 90 days prior to admission. |
| Facility failed to ensure that the person who develops the Individualized Service Plan (ISP) has completed approved training. |
| Facility failed to retain resident records for at least one year after discharge. |
| Facility failed to ensure medication and dietary supplements are stored so they are not accessible to other residents. |
| Facility failed to ensure that over-the-counter medication is labeled with the resident's name or in a pharmacy-issued container until administered. |
| Facility failed to ensure common face/hand washing sinks have paper towels or an air dryer and liquid soap. |
Inspection Report
Monitoring
Census: 1
Deficiencies: 0
Apr 20, 2021
Visit Reason
A mandated monitoring inspection was initiated due to a state of emergency health pandemic declared by the Governor of Virginia, conducted remotely from 4/6/2021 to 4/20/2021.
Findings
The inspection reviewed one resident record, one staff record, local fire and health inspections, and other documentation. All background checks for staff hired after the most recent inspection were reviewed. No violations with applicable standards or law were found and no deficiencies were issued.
Inspection Report
Monitoring
Census: 1
Deficiencies: 0
Feb 16, 2021
Visit Reason
A mandated monitoring inspection was initiated due to a state of emergency health pandemic declared by the Governor of Virginia and conducted remotely.
Findings
The inspection found no violations with applicable standards or law after reviewing resident and staff records, medication administration records, local fire and health inspections, and background checks.
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