Inspection Report
Monitoring
Deficiencies: 0
Nov 5, 2025
Visit Reason
The inspection was a monitoring visit conducted to review resident care and related services at the assisted living facility.
Findings
The investigation did not support the self-report of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Report Facts
Resident records reviewed: 4
Staff records reviewed: 1
Resident interviews conducted: 1
Staff interviews conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Inspector conducting the monitoring visit |
Inspection Report
Monitoring
Census: 67
Deficiencies: 4
Apr 16, 2025
Visit Reason
The inspection was a monitoring visit to assess compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection identified multiple violations related to staff tuberculosis risk assessments, medication orders following hospital admissions, medication administration according to physician instructions, and availability of PRN medications. Plans of correction were submitted to address these deficiencies.
Deficiencies (4)
| Description |
|---|
| Facility did not ensure that each staff member annually submits the results of a tuberculosis risk assessment. |
| Facility did not ensure that new orders were obtained for all medications and treatments prior to a resident's return following a hospital admission. |
| Facility did not ensure that medication was administered in accordance with the physician's instructions. |
| Facility did not ensure that PRN medications were available and properly stored at the facility. |
Report Facts
Number of residents present: 67
Number of resident records reviewed: 6
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Inspector conducting the monitoring visit |
| Resident Care Director | Named in plans of correction related to medication administration and audits | |
| Executive Director | Responsible for implementation and ongoing compliance with plans of correction | |
| Human Resource Coordinator | Conducted audit of employee annual TB screenings | |
| Wellness Nurse | Received re-education regarding hospital discharge summary utilization | |
| Medication Technician | Received refresher training regarding reordering medications timely |
Inspection Report
Monitoring
Census: 75
Deficiencies: 2
Mar 4, 2025
Visit Reason
The inspection was a monitoring visit conducted over multiple days to review compliance with resident care and related services, including additional requirements for adults with serious cognitive impairments.
Findings
The investigation found non-compliance with medication management standards, including errors in transcription of medication administration records and administration of medication without valid physician orders. Violations were issued and plans of correction were required.
Deficiencies (2)
| Description |
|---|
| The facility did not ensure that the medication management plan was implemented to accurately transcribe medication administration records within 24 hours of receipt of a new order. |
| The facility failed to ensure that no medication or dietary supplement was started, changed, or discontinued without a valid physician order. |
Report Facts
Number of residents present: 75
Number of resident records reviewed: 7
Number of resident interviews: 3
Number of staff interviews: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Inspector conducting the monitoring inspection |
| Resident Care Director | Named in relation to conducting audits and implementing plans of correction | |
| Executive Director | Responsible for implementation and ongoing compliance with the plan of correction |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 1
Mar 4, 2025
Visit Reason
The inspection was conducted in response to complaints received by VDSS Division of Licensing on 2025-02-14 and 2025-03-31 regarding allegations in the areas of Resident Care and Related Services and Resident Accommodations and Related Provisions.
Findings
The investigation supported the allegation of non-compliance with standards or law related to resident care. Specifically, the facility failed to ensure that the health care service needs of residents were met, as evidenced by incomplete blood pressure monitoring for Resident #1. Violations were issued and a plan of correction was provided.
Complaint Details
Complaints were substantiated based on evidence gathered during the investigation regarding failure to meet health care service needs in resident care and accommodations.
Deficiencies (1)
| Description |
|---|
| Facility did not ensure that the health care service needs of residents are met, specifically incomplete blood pressure monitoring for Resident #1. |
Report Facts
Number of residents present: 75
Number of resident records reviewed: 3
Number of resident interviews: 3
Number of staff interviews: 3
Blood pressure checks for Resident #1: 19
Blood pressure checks for Resident #1: 20
Blood pressure checks for Resident #1: 15
Blood pressure checks for Resident #1: 11
Blood pressure checks for Resident #1: 5
Blood pressure checks for Resident #1: 1
Blood pressure checks for Resident #1: 5
Blood pressure checks for Resident #1: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Inspector conducting the complaint investigation |
| Resident Care Director | Resident Care Director (RCD) | Provided refresher training to Wellness Nurse and responsible for auditing medication orders and ongoing compliance |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 28, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the Fairfax Licensing Office on December 18, 2024, concerning Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted at the facility.
Complaint Details
Complaint was related to Resident Care and Related Services; the allegation was not substantiated based on the investigation.
Report Facts
Number of resident records reviewed: 2
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 29, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2024-09-13 regarding allegations in the areas of Resident Care and Related Services.
Findings
The investigation supported the allegation of non-compliance related to resident care, specifically that the facility did not ensure residents' health care service needs were met and that medications or treatments were administered without valid physician orders.
Complaint Details
The complaint was substantiated based on record review and evidence that the facility failed to meet health care service needs and proper medication order protocols for Resident #1.
Deficiencies (2)
| Description |
|---|
| The facility did not ensure that the health care service needs of residents are met, as evidenced by Resident #1 not attending a scheduled GI consult and follow-up care not being completed. |
| The facility did not ensure that no medication, medical procedure, or treatment is started, changed, or discontinued without a valid order from a physician or other prescriber, as Resident #1 received Premarin cream two times per day without a physician's order. |
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Jul 9, 2024
Visit Reason
The inspection was conducted as a complaint investigation to review allegations related to the facility's compliance with standards and laws.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Administration and Administrative Services. Specifically, the facility failed to report major incidents affecting resident safety within 24 hours as required.
Complaint Details
The complaint investigation found that the facility did not submit incident reports for injuries to Resident 1, including a healing bruise and a painful bump on the forehead. Some allegations were substantiated while others were not.
Deficiencies (1)
| Description |
|---|
| Facility failed to report to the regional office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of a resident. |
Report Facts
Number of residents present: 73
Number of resident records reviewed: 1
Number of staff records reviewed: 5
Number of staff interviews conducted: 2
Plan of Correction monitoring start date: Oct 1, 2024
Plan of Correction monitoring duration: 2
Inspection Report
Renewal
Census: 68
Deficiencies: 0
Feb 28, 2024
Visit Reason
The inspection was a renewal inspection conducted to review compliance with licensing requirements for the assisted living facility.
Findings
The licensing inspector reviewed multiple areas including resident records, staff records, medication administration, and facility reports such as health inspection and fire marshal reports. Observations included resident activities and medication administration.
Report Facts
Resident Records Reviewed: 5
Staff Records Reviewed: 3
Staff Interviews Conducted: 5
Resident Interviews Conducted: 2
Inspection Report
Monitoring
Census: 73
Deficiencies: 0
May 25, 2023
Visit Reason
The inspection was a monitoring visit to review various areas including administration, personnel, resident care, and emergency preparedness at the assisted living facility.
Findings
The inspection included review of 8 records and 6 interviews, observation of residents during lunch and activities, and assessment of all facility self-reported incidents since the last inspection.
Report Facts
Records reviewed: 8
Interviews conducted: 6
Inspection Report
Monitoring
Census: 45
Deficiencies: 0
Jan 26, 2022
Visit Reason
A monitoring inspection was conducted to review compliance with regulations including staff background checks, resident care, and facility conditions.
Findings
No violations were found during the inspection. Fire and health inspections were current, staff and resident records were reviewed, and activities met different levels of care needs.
Inspection Report
Renewal
Census: 72
Deficiencies: 0
Jan 4, 2021
Visit Reason
A mandated renewal inspection was initiated on January 4, 2021 and concluded on January 5, 2021, conducted remotely due to a state of emergency health pandemic.
Findings
The inspection reviewed resident and staff records, medication administration, local fire and health inspections, and background checks. No violations with applicable standards or law were found and no violations were issued.
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