Inspection Reports for Hunters Woods at Trails Edge
2222 Colts Neck Rd, Reston, VA 20191, United States, VA, 20191
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Census Over Time
Inspection Report
Monitoring
Census: 107
Deficiencies: 2
Aug 19, 2025
Visit Reason
The inspection was a monitoring visit conducted on August 19, 2025, following a self-reported incident received on August 2, 2025, regarding allegations in Resident Care and Related Services and Staffing and Supervision.
Findings
The investigation supported the self-report of non-compliance with standards related to resident safety and supervision. Violations were issued for failure to assume general responsibility for a resident's health, safety, and well-being, including failure to prevent elopement from the secure unit.
Deficiencies (2)
| Description |
|---|
| The facility failed to assume general responsibility for the health, safety, and well-being of a resident in their care, evidenced by an elopement incident on 08/02/2025. |
| The facility failed to ensure supervision of resident schedules, care, and activities including prevention of wandering from the premises, as evidenced by the elopement of Resident 1 on 08/02/2025. |
Report Facts
Number of residents present: 107
Number of resident records reviewed: 1
Number of staff records reviewed: 3
Number of staff interviews conducted: 2
Time alarm was cleared: 3.47
Time resident not found during safety rounds: 4.45
Time resident located by police: 6.2
Distance resident found from facility: 0.03
Temperature: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Confirmed details in the incident report regarding the elopement and acknowledged potential compromise of resident's health and safety | |
| Staff 3 | Cleared the door alarm at 3:47 a.m. but did not check for resident exiting | |
| Staff 5 | Observed resident missing during safety rounds at 4:45 a.m. and completed communication log | |
| Wellness Director | Completed head-to-toe assessment, notified responsible party and physician, counseled staff, and conducted inservice and monitoring | |
| Director of Facilities | Increased timing and volume of egress alarm, added signage, and changed alarm silencing function | |
| Memory Care Director | Conducted staff inservice on elopement policies and elopement drills |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 1
Jul 29, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2025-07-06 regarding allegations in the areas of Resident Care and Related Services, Buildings and Grounds.
Findings
The investigation supported some of the allegations, finding non-compliance in Direct Care and Related Services and Buildings and Grounds. A violation notice was issued related to the facility's failure to maintain the interior of the building in good repair and cleanliness.
Complaint Details
The complaint was substantiated in part; evidence supported some allegations of non-compliance in resident care and building maintenance.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the interior of the building was maintained in good repair and kept clean, specifically noting stained and worn carpet in a resident's apartment. |
Report Facts
Number of residents present: 119
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 1
Mar 26, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 02/18/2025 regarding allegations in the area of resident care and related services.
Findings
The investigation found some areas of non-compliance with standards related to resident care and related services. Specifically, the facility failed to ensure prompt response by staff to resident needs, as evidenced by delayed call bell response times.
Complaint Details
The complaint was substantiated in part; evidence supported some but not all allegations related to resident care and related services. A violation notice was issued.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure a prompt response by staff to resident needs as reasonable to the circumstances, with 7 call bell response times exceeding 20 minutes for one resident. |
Report Facts
Call bell response times exceeding 20 minutes: 7
Number of residents present: 118
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Number of collateral interviews conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Current inspector conducting the complaint investigation |
| Jacquelyn Kabiri | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Monitoring
Census: 120
Deficiencies: 1
Feb 26, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with staffing, resident care, and accommodations regulations, following a self-reported incident regarding resident care.
Findings
The investigation did not substantiate the self-reported non-compliance, but violations unrelated to the self-report were identified, including failure to update an Individualized Service Plan (ISP) after fall risk assessments.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the Individualized Service Plan (ISP) included a written description of services to address identified needs and who will provide them. |
Report Facts
Number of residents present: 120
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of resident interviews conducted: 1
Number of staff interviews conducted: 3
Plan of correction audit period: 90
Plan of correction completion date: Mar 15, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Current inspector conducting the inspection |
| Jacquelyn Kabiri | Licensing Inspector | Contact person for questions regarding the inspection |
| Health & Wellness Director | Responsible for plan of correction implementation | |
| Staff 1 | Acknowledged resident's ISP during inspection |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Feb 5, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-01-10 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. No violations were cited and no violation notice was issued.
Complaint Details
A complaint was received on 2025-01-10 regarding Resident Care and Related Services. The evidence gathered did not support the allegations of non-compliance.
Report Facts
Number of residents present: 107
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: 3
Inspection Report
Monitoring
Census: 110
Deficiencies: 3
Oct 16, 2024
Visit Reason
The inspection was a monitoring visit conducted to review compliance with regulations following a self-report received regarding allegations in Resident Care and Related Services.
Findings
The investigation did not substantiate the allegations of noncompliance; however, violations unrelated to the complaint were identified, including failures to obtain required signatures on resident orientation, individualized service plans, and staff training acknowledgments.
Complaint Details
The visit was not complaint-related; a self-report was received but the evidence did not support allegations of noncompliance.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure the resident's acknowledgment of having received orientation upon admission was signed and dated by the resident. |
| Facility failed to ensure the individualized service plan (ISP) was signed and dated by the resident or legal representative. |
| Facility failed to ensure the written acknowledgment of the Resident's rights and responsibilities training was signed and dated by staff. |
Report Facts
Number of residents present: 110
Number of resident records reviewed: 2
Number of staff records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Current inspector conducting the inspection |
| Jacquelyn Kabiri | Licensing Inspector | Contact person for questions about the inspection |
| Staff 1 | Interviewed staff who confirmed missing signatures on resident orientation, ISP, and staff training acknowledgments |
Inspection Report
Monitoring
Census: 106
Deficiencies: 2
Oct 16, 2024
Visit Reason
The inspection was conducted as a monitoring visit following a self-report received by VDSS Division of Licensing regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with facility policies and medication administration standards, resulting in violations issued. The facility failed to follow its own policies on telephone orders for medications and failed to ensure medications were administered according to physician instructions.
Deficiencies (2)
| Description |
|---|
| Facility failed to follow their own policies and procedures regarding telephone orders for new medications. |
| Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions, resulting in a medication error. |
Report Facts
Number of residents present: 106
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with staff: 1
Medication dosage: 10
Medication dosage: 10
Medication dosage: 20
Medication dosage: 20
Plan of correction timeframe: 3
Plan of correction timeframe: 5
Inspection time: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Current inspector conducting the inspection |
| Jacquelyn Kabiri | Licensing Inspector | Contact person for questions about VDSS Licensing Programs |
| Director of Nursing | Oversees training, compliance, and audit findings related to medication order policies and corrections |
Inspection Report
Renewal
Census: 88
Deficiencies: 7
Apr 25, 2024
Visit Reason
The inspection was conducted as a renewal of the facility's license to ensure compliance with applicable standards and laws.
Findings
The inspection identified multiple violations related to resident safety, individualized service plans, diet orders, medication management, and staff criminal history record checks. The facility was found non-compliant with several standards and issued violation notices with opportunities to submit plans of correction.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure harmful ordinary materials or objects were inaccessible to residents except under staff supervision. |
| Failed to ensure hospice care services were included in the individualized service plan (ISP) and coordinated with hospice organizations. |
| Individualized service plans (ISPs) were not updated at least annually or as needed for changes in resident condition, lacking time frames and outcome descriptions. |
| Failed to prepare and serve diets according to physician or prescriber orders, including diabetic and pureed diets. |
| Facility medication management plan was not fully implemented; an opened insulin pen lacked date of opening and discard date. |
| Failed to document all administered medications on medication administration records (MAR), including missing documentation of a second dose of potassium chloride. |
| Failed to obtain criminal history record reports on or prior to the 30th day of employment for several staff members. |
Report Facts
Number of residents present: 88
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews: 3
Number of staff interviews: 4
Number of medication doses ordered: 2
Number of staff with missing criminal history reports: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Contact person for questions about the inspection |
| Amanda Velasco | Current Inspector | Inspector conducting the inspection |
Inspection Report
Monitoring
Deficiencies: 0
Mar 16, 2023
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 2023-03-08 regarding allegations in staffing and supervision, resident care and related services, buildings and grounds, and additional requirements for facilities caring for adults with serious cognitive impairments.
Findings
The licensing inspector completed a tour of the physical plant and reviewed relevant areas. The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The inspection findings will be posted publicly.
Report Facts
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: 3
Inspection Report
Monitoring
Census: 86
Deficiencies: 0
Feb 23, 2023
Visit Reason
The inspection was a monitoring visit conducted to review staffing, resident care, and building conditions at the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector observed adequate staffing and secured doors in the memory care unit.
Report Facts
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
Renewal
Census: 86
Deficiencies: 0
Feb 23, 2023
Visit Reason
The inspection was conducted as a renewal inspection to verify compliance prior to the expiration of the current license.
Findings
The inspection found no violations with applicable standards or laws. The licensing inspector completed a tour of the physical plant and observed medication administration and residents eating lunch.
Report Facts
Resident records reviewed: 10
Staff records reviewed: 5
Residents present: 86
Inspection Report
Monitoring
Census: 85
Deficiencies: 1
Jan 17, 2023
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of resident care and related services.
Findings
The investigation supported the self-report of non-compliance related to supervision failures, specifically a resident elopement incident. Violations were issued based on review of records, interviews, and camera footage showing a resident exited the secure environment unsupervised and was found offsite.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering from the premises. |
Report Facts
Number of residents present: 85
Date of resident admission: Dec 12, 2022
Time resident exited facility: 2036
Distance from facility: 800
Inspection Report
Monitoring
Census: 80
Deficiencies: 0
Dec 16, 2022
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on 11/25/2022 regarding allegations in the areas of personnel and resident care and related services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. No deficiencies were explicitly stated in the report.
Report Facts
Number of resident records reviewed: 2
Number of staff records reviewed: 1
Number of interviews conducted with staff: 1
Inspection Report
Monitoring
Census: 67
Deficiencies: 2
Jun 13, 2022
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 with applicable standards related to employment records, specifically incomplete sworn statements of affirmation and delayed criminal history record reports for some employees. Violations were documented and a plan of correction was requested.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that applicants provide a sworn statement of affirmation; several employees had incomplete statements. |
| Facility failed to ensure criminal history record reports were obtained on or prior to the 30th day of employment for some employees. |
Report Facts
Number of residents present: 67
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 0
Number of employees with incomplete sworn statements: 10
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 16, 2021
Visit Reason
An announced complaint investigation was conducted regarding resident rights and exploitation at Hunters Woods at Trails Edge on July 16, 2021, August 20, 2021, and November 27, 2021.
Findings
The investigation included review of resident records, documentation, and interviews with residents and staff. The complaint was deemed not valid as the preponderance of evidence did not support the allegations.
Complaint Details
Complaint related to resident rights and exploitation; complaint deemed not valid based on evidence gathered during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 7, 2021
Visit Reason
A non-mandated complaint inspection was initiated due to allegations regarding staffing and resident care at the facility.
Findings
The investigation found non-compliance with standards related to the failure to ensure that care and services specified in the Individualized Service Plan (ISP) were provided to residents, specifically regarding assistance with hearing aids.
Complaint Details
The complaint was substantiated as evidence supported the allegation of non-compliance with standards or law related to staffing and resident care.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that the care and services specified in the Individualized Service Plan (ISP) are provided to each resident, including assistance with hearing aids. |
Report Facts
Dates of visits by Collateral 2 and Collateral 3: 16
Inspection Report
Complaint Investigation
Deficiencies: 6
Jun 30, 2021
Visit Reason
A non-mandated complaint inspection was initiated due to allegations regarding staffing and resident care. The inspection included on-site observations and document reviews to investigate the complaint.
Findings
The investigation found multiple violations related to failure to provide accurate disclosure statements, inadequate personal care including bathing, failure to document medical attention after serious incidents, restricted resident freedom of movement, medication management deficiencies, and lack of staff awareness regarding residents' Do Not Resuscitate orders.
Complaint Details
The complaint was substantiated with evidence supporting non-compliance in staffing and resident care standards.
Deficiencies (6)
| Description |
|---|
| Facility failed to provide a statement to prospective resident and legal representative disclosing accurate staffing information. |
| Facility failed to ensure personal assistance and care with bathing at least twice a week as needed. |
| Facility failed to document medical attention and circumstances after resident's serious accident and hospitalization. |
| Facility failed to provide freedom of movement; residents in Safe, Secure Unit were locked out of their rooms. |
| Facility failed to implement a written medication management plan ensuring timely filling and accurate transcription of medication orders. |
| Facility failed to ensure all staff are aware of residents with valid Do Not Resuscitate orders. |
Report Facts
Inspection dates: Inspection conducted on June 30, 2021 and July 7, 2021
Resident hospitalization dates: Resident 1 hospitalized from 05/22/2021 to 05/23/2021
Medication unavailability dates: Clonazepam not available on 03/6, 03/8, 03/9, 03/10/2021; Acetaminophen not available on 05/25, 05/29, 05/30/2021
Inspection Report
Deficiencies: 1
Jun 30, 2021
Visit Reason
The inspection was an unannounced visit conducted in response to a self-reported incident involving a resident wandering from the premises.
Findings
The facility failed to ensure adequate supervision of resident schedules, care, and activities, specifically regarding the prevention of wandering. A resident was found outside the facility after leaving unnoticed due to a malfunction with the wander device system.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide supervision to prevent wandering from the premises, as evidenced by a resident leaving the building unnoticed and the wander device not activating when doors were already open. |
Report Facts
Incident date: May 15, 2021
Incident report date: May 16, 2021
Resident Uniform Assessment Instrument date: Apr 5, 2021
Individualized Service Plan date: Apr 12, 2021
Inspection Report
Deficiencies: 2
Jun 30, 2021
Visit Reason
Unannounced inspection conducted in response to a self-reported incident involving a resident wandering from the facility.
Findings
The facility failed to report a major incident within 24 hours as required and failed to provide adequate supervision to prevent a resident from wandering off the premises. Violations were cited related to incident reporting and supervision.
Deficiencies (2)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident. |
| Facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs such as prevention of wandering from the premises. |
Report Facts
Incident report date: May 28, 2021
Incident report submission date: May 30, 2021
Inspection Report
Routine
Census: 60
Deficiencies: 2
Feb 11, 2021
Visit Reason
The inspection was conducted using an alternate remote protocol due to a state of emergency health pandemic declared by the Governor of Virginia. The inspection was initiated to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified non-compliance with standards related to assessment of residents with serious cognitive impairments and accuracy of sworn statements by staff. Violations were documented on a violation notice and require a plan of correction.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure residents admitted to the Safe, Secure Unit had been assessed by an independent clinical psychologist or physician for serious cognitive impairment as required. |
| Facility failed to ensure that any person making a materially false statement on the sworn statement or affirmation shall be guilty of a Class 1 misdemeanor; staff sworn statement contained inaccurate information. |
Report Facts
Resident records reviewed: 4
Staff records reviewed: 4
Days to return plan of correction: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #13 | Named in deficiency related to inaccurate sworn statement | |
| Amanda Velasco | Inspector | Current inspector conducting the inspection |
| Resident Wellness Director | Resident Wellness Director | Responsible for ensuring completion and accuracy of Serious Cognitive Impairment forms |
| Administrative Services Director | Administrative Services Director | Responsible for reviewing pre-hire paperwork and sworn statements |
| Executive Operations Officer | Executive Operations Officer | Responsible for auditing pre-hire sworn statements |
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