Inspection Report
Monitoring
Census: 72
Deficiencies: 0
Aug 28, 2025
Visit Reason
The inspection was a monitoring visit conducted over three dates to review resident care and related services following a self-reported allegation received by the licensing office.
Findings
The investigation found no evidence to support the self-report of non-compliance with standards or law. The inspection summary will be posted publicly.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 2
Number of interviews conducted with residents: 0
Inspection Report
Monitoring
Census: 73
Deficiencies: 0
Aug 19, 2025
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review resident care, related services, and personnel at the facility.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The inspection findings were satisfactory with no substantiated deficiencies.
Report Facts
Resident records reviewed: 1
Resident interviews conducted: 1
Staff interviews conducted: 1
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 0
Aug 19, 2025
Visit Reason
A complaint was received by the Fairfax Licensing Office on 2025-08-15 regarding allegations in the area of Resident Care and Related Services, prompting a complaint inspection on 2025-08-19.
Findings
The evidence gathered during the inspection determined no violations with applicable standards or law. The investigation did not support the allegation of non-compliance.
Complaint Details
Complaint related to Resident Care and Related Services; the complaint was not substantiated as no violations were found.
Report Facts
Resident records reviewed: 1
Staff interviews conducted: 1
Inspection Report
Complaint Investigation
Deficiencies: 5
Aug 6, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-07-25 regarding allegations related to Resident Care and Related Services and Safe, Secure Environment at the facility.
Findings
The investigation found multiple violations including failure to keep resident records and medication storage areas locked, improper medication administration not in accordance with physician instructions, and incomplete medication administration records. Evidence supported the allegations of noncompliance.
Complaint Details
The complaint was substantiated as evidence gathered during the investigation supported the allegations of noncompliance with standards and laws related to resident care and medication administration.
Deficiencies (5)
| Description |
|---|
| Facility did not ensure that resident records are kept in a locked area. |
| Facility did not ensure that the medication storage area remains locked. |
| Medication storage was not limited to an out-of-sight place in rooms of residents who are not capable of self-administering medication. |
| Medications were not administered in accordance with physician's instructions, including missed doses and lack of documentation. |
| Medication administration records (MAR) did not include all required information and documentation of medication administration was incomplete. |
Report Facts
Number of resident records reviewed: 5
Number of resident interviews conducted: 4
Number of staff interviews conducted: 4
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
Jul 21, 2025
Visit Reason
The inspection was conducted in response to a complaint received on July 17, 2025, regarding allegations related to staffing and additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The evidence gathered during the inspection determined no violations with applicable standards or law. The investigation did not support the allegation of non-compliance.
Complaint Details
Complaint was related to staffing and additional requirements for adults with serious cognitive impairments. The complaint was not substantiated.
Report Facts
Number of residents present: 72
Number of resident records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 21, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on July 8, 2025, regarding an allegation in the area of Resident Care and Related Services.
Findings
The investigation found non-compliance with standards related to resident rights, specifically that the facility did not ensure resident rights were reviewed annually with each staff person. Violations were issued based on these findings.
Complaint Details
The complaint was substantiated as the evidence gathered supported the allegation of non-compliance with resident rights review requirements.
Deficiencies (1)
| Description |
|---|
| The facility did not ensure that resident rights are reviewed annually with each staff person. |
Report Facts
Number of resident records reviewed: 4
Number of staff interviews conducted: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Named in deficiency for not having current annual review of resident rights; hired 9/18/23 with last review in March 2024 |
Inspection Report
Monitoring
Census: 69
Deficiencies: 5
Apr 23, 2025
Visit Reason
The inspection was a monitoring visit to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found multiple violations including failure to ensure individualized service plans were properly signed, inadequate supervision of residents leading to elopement, medication management deficiencies including missed and improperly stored medications, and lack of availability of PRN medications.
Deficiencies (5)
| Description |
|---|
| Facility did not ensure that the individualized service plan (ISP) is signed by the administrator or the resident/legal representative. |
| Facility did not provide supervision of resident schedules, care, and activities including attention to specialized needs such as wandering from the premises. |
| Facility did not ensure that the medication management plan was implemented to ensure timely filling and refilling of prescription medications to avoid missed dosages. |
| Facility did not ensure that medication storage is limited to an out-of-sight place in rooms of residents capable of self-administering medication. |
| Facility did not ensure that medications ordered for PRN administration were available and properly stored at the facility. |
Report Facts
Number of residents present: 69
Number of resident records reviewed: 6
Number of resident interviews conducted: 6
Number of staff interviews conducted: 5
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 19, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-11-04 regarding allegations in the areas of Staffing and Supervision; Admission Retention and Discharge of Residents; Resident Care and Related Services; and Building and Grounds.
Findings
The investigation supported some, but not all, of the allegations. Non-compliance was found in the area of Resident Care and Related Services, specifically regarding medication administration timing.
Complaint Details
Complaint related: Yes. The evidence gathered supported some of the allegations related to Resident Care and Related Services. A violation notice was issued.
Deficiencies (1)
| Description |
|---|
| Facility did not ensure that medications are administered within one hour before, and one hour after, the facility's standard dosing schedule. |
Report Facts
Number of resident records reviewed: 3
Number of interviews conducted with staff: 2
Medication administration times: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Monitoring
Deficiencies: 2
Nov 19, 2024
Visit Reason
The inspection was a monitoring visit conducted on November 19 and 21, 2024, to review compliance with regulations related to admission, retention, discharge of residents, and resident care and related services.
Findings
The inspection found non-compliance with applicable standards and laws, resulting in documented violations related to resident safety and supervision, particularly concerning residents presenting imminent physical threats and supervision of residents with cognitive impairments.
Deficiencies (2)
| Description |
|---|
| The facility did not ensure that individuals presenting imminent physical threat or danger to self or others were appropriately managed. |
| The facility did not ensure supervision of resident schedules, care, and activities, including prevention of falls and wandering, especially in the memory care unit. |
Report Facts
Number of resident records reviewed: 3
Number of interviews conducted with staff: 3
Number of interviews conducted with residents: 0
Dates of self-reported incidents: Incidents reported on 8/2/24, 8/13/24, and 11/6/24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Inspector conducting the monitoring visit |
Inspection Report
Complaint Investigation
Deficiencies: 3
Oct 7, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-09-27 regarding an allegation in the area of Resident Care and Related Services at Sunrise of Fairfax.
Findings
The investigation found non-compliance with standards related to failure to report a major incident within 24 hours, failure to notify the resident's physician and designated contact within 24 hours of a serious injury, and failure to comply with physician-prescribed care such as weekly weighing of the resident. Violations were issued based on these findings.
Complaint Details
The complaint investigation was substantiated with violations issued. The complaint involved failure to notify appropriate parties about a resident's serious wound condition and failure to comply with care standards.
Deficiencies (3)
| Description |
|---|
| Facility did not ensure a report was made to the regional licensing office within 24 hours of a major incident affecting resident safety (stage four pressure wound). |
| Facility did not ensure that the resident's physician and designated contact person were contacted within 24 hours of a serious injury or medical condition. |
| Facility did not ensure compliance with physician-prescribed care, including weekly weighing and notification of weight changes. |
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Inspection dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Routine
Census: 57
Deficiencies: 1
Mar 7, 2024
Visit Reason
The inspection was a routine visit to review compliance with applicable standards and laws, including administration, resident care, emergency preparedness, and medication management.
Findings
The inspection found non-compliance with the facility's medication management plan, specifically a failure to document communication regarding a medication being on hold and the plan for correction of the missed dose.
Deficiencies (1)
| Description |
|---|
| Facility staff failed to follow the facility's medication management plan by not documenting communication to the physician regarding a medication on hold and not documenting the plan for correction of the missed dose. |
Report Facts
Number of residents present: 57
Number of resident records reviewed: 4
Number of staff records reviewed: 4
Number of interviews with residents: 2
Number of interviews with staff: 5
Number of Wellness TM and MT staff: 11
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 24, 2023
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2023-08-04 regarding allegations in the areas of staffing and supervision, and resident care and related services.
Findings
The investigation supported some, but not all, of the allegations. Areas of non-compliance were found related to resident care and related services, specifically the failure to ensure that the individualized services plan (ISP) was signed and dated by the resident or their legal representative.
Complaint Details
The complaint was substantiated in part; evidence showed the ISP for Resident #2 completed on 2023-04-26 was not signed by the resident or legal representative.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that the individualized services plan (ISP) was signed and dated by the resident or his legal representative. |
Report Facts
Number of resident records reviewed: 8
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 3
Inspection Report
Renewal
Census: 40
Deficiencies: 4
Feb 9, 2023
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with applicable standards and laws prior to license renewal.
Findings
The inspection found multiple areas of non-compliance including failure to complete the UAI prior to admission and annually, failure to update Individualized Service Plans to reflect current resident needs, inadequate supervision of residents leading to unsupervised exits from secure areas, and incomplete documentation of rehabilitative services. Plans of correction were submitted to address these deficiencies.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure that the UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition. |
| Facility failed to ensure that Individualized Service Plans (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition. |
| Facility failed to ensure supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises. |
| Facility failed to ensure that the services provided, evaluations of progress, and other pertinent information regarding the rehabilitative services shall be recorded in the resident's record. |
Report Facts
Residents in care at time of inspection: 40
Resident records sampled: 7
Staff records sampled: 4
Individual interviews conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Inspector | Current inspector conducting the inspection |
| Sharae Henderson | Licensing Administrator | Referenced in technical assistance for updating posted resident rights |
| Lynette Storr | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Renewal
Census: 9
Deficiencies: 0
Mar 9, 2022
Visit Reason
An unannounced renewal inspection was conducted to review compliance with licensing requirements and regulations.
Findings
The inspection included review of resident and staff records, background checks, and medication administration. No violations were cited during this inspection.
Report Facts
Resident records reviewed: 4
Staff records reviewed: 3
Individual interviews: 1
Inspection Report
Monitoring
Census: 5
Deficiencies: 0
Jan 24, 2022
Visit Reason
An unannounced monitoring inspection was conducted to review resident and staff records, medication administration, and compliance with various regulatory provisions.
Findings
No violations were cited during the inspection. Resident and staff records, police reports, and medication administration were reviewed with no deficiencies found.
Report Facts
Resident records reviewed: 2
Staff records reviewed: 3
Residents present: 5
Inspection Report
Original Licensing
Deficiencies: 0
Sep 23, 2021
Visit Reason
An announced initial inspection was conducted as part of the original licensing process for Sunrise of Fairfax assisted living facility.
Findings
The Licensing Inspector walked the physical plant, verified window and room measurements, reviewed policies, procedures, and staff records, and tested the call bell system. No violations were cited during this inspection.
Report Facts
Days for license issuance: 60
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