Deficiencies per Year
4
3
2
1
0
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 0
Jul 31, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the Fairfax Licensing Office on July 7, 2025, regarding allegations in the areas of Personnel, Resident Care, and Related Services.
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 allegations in Personnel, Resident Care, and Related Services; the complaint was not substantiated.
Report Facts
Number of resident records reviewed: 2
Number of interviews conducted with staff: 12
Inspection Report
Monitoring
Census: 100
Deficiencies: 1
May 30, 2025
Visit Reason
The inspection was a monitoring visit conducted on May 30 and June 3, 2025, to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance related to medication management, specifically that PRN medications ordered were not available and properly stored at the facility. A violation notice was issued and a plan of correction was submitted.
Deficiencies (1)
| Description |
|---|
| Facility did not ensure that medications ordered for PRN administration were available and properly stored. |
Report Facts
Number of residents present: 100
Number of resident records reviewed: 6
Number of interviews with residents: 3
Number of interviews with staff: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Inspector conducting the monitoring inspection |
| Director of Nursing | Reviewed monthly audit results and confirmed receipt of medications | |
| Wellness Nurse | Confirmed receipt of medications along with Director of Nursing | |
| Executive Director | Responsible for ensuring implementation and ongoing compliance with the plan of correction |
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 1
May 30, 2025
Visit Reason
The inspection was conducted in response to complaints received by VDSS Division of Licensing on May 9, 2025, regarding allegations in the areas of Administration and Administrative Services, Admissions and Discharges, and Resident Care and Related Services.
Findings
The investigation supported some, but not all, of the allegations of non-compliance. The substantiated complaint area was Resident Care and Related Services. A violation notice was issued, and the licensee was given the opportunity to submit a plan of correction.
Complaint Details
The complaint investigation substantiated non-compliance in Resident Care and Related Services. The complaint was related to failure to provide services as specified in the individualized service plan. Resident #1 was independent and did not require an ISP, but the facility had chosen to maintain one for awareness. The facility plans to update ISPs if independent residents refuse monthly weights or vitals.
Deficiencies (1)
| Description |
|---|
| The facility did not ensure that the services specified in the individualized service plan (ISP) were provided to each resident, specifically Resident #1's weight/vitals were not documented as taken monthly by facility staff. |
Report Facts
Number of residents present: 100
Number of resident records reviewed: 3
Number of interviews with residents: 1
Number of interviews with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 0
May 30, 2025
Visit Reason
The inspection was conducted in response to multiple complaints received by the VDSS Division of Licensing regarding various regulatory allegations.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or laws. The inspection summary will be publicly posted.
Complaint Details
Complaints were received on 5/1/25, 5/7/25, 5/8/25, 5/9/25, 5/12/25, and 5/22/25 regarding allegations across multiple regulatory parts. The evidence gathered did not substantiate the allegations.
Report Facts
Number of residents present: 100
Number of resident records reviewed: 2
Number of resident interviews: 1
Number of staff interviews: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 0
May 30, 2025
Visit Reason
The inspection was conducted in response to complaints received by VDSS Division of Licensing on May 1, 2025, regarding allegations related to Parts III, VI, and VII of the regulations.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection summary will be posted publicly within five business days.
Complaint Details
Complaints were received on 5/1/25 regarding allegations in Parts III, VI, and VII of the regulations. The evidence gathered did not support the allegations.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Monitoring
Deficiencies: 4
Sep 20, 2024
Visit Reason
The inspection was a monitoring visit conducted on September 20, 2024 and October 4, 2024, including a tour of the facility and review of documentation following a self-reported incident regarding Resident Care and Related Services.
Findings
The inspection found multiple violations related to staff training in cognitive impairment, medication administration licensure, medication handling, and medication administration timing. Staff member #1 was found non-compliant with training and licensure requirements and was relieved of medication duties. The facility implemented corrective actions including audits, training, and ongoing monitoring to ensure compliance.
Deficiencies (4)
| Description |
|---|
| Facility did not ensure each staff member attends at least 10 hours of training in cognitive impairment within four months of employment. |
| Facility did not ensure each staff person administering medication is authorized by Virginia Drug Control Act. |
| Facility did not ensure medications remain in the pharmacy issued container until administered to the resident. |
| Facility did not ensure medications are administered within one hour before or after the facility's standard dosing schedule. |
Report Facts
Number of resident records reviewed: 2
Number of staff records reviewed: 1
Number of resident interviews conducted: 1
Number of staff interviews conducted: 2
Hours of cognitive impairment training attended by Staff #1: 8.5
Date Staff #1 relieved of medication duties: Sep 22, 2024
Medication administration observation period: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Conducted the inspection |
| Staff #1 | Named in multiple medication administration and training deficiencies | |
| Team Member Services Manager | Responsible for audits and implementation of plan of correction | |
| Executive Director | Responsible for ensuring implementation and ongoing compliance with plan of correction | |
| Director of Nursing | Involved in notification, corrective actions, and ongoing monitoring related to medication administration deficiencies |
Inspection Report
Renewal
Census: 111
Deficiencies: 1
Jun 3, 2024
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for continued licensing of the assisted living facility.
Findings
The inspection found non-compliance with applicable standards related to staff training requirements. Specifically, direct care staff did not meet the required 12 hours of annual training.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure direct care staff attended 12 hours of training annually. |
Report Facts
Residents present: 111
Resident records reviewed: 8
Staff records reviewed: 4
Interviews with residents: 1
Interviews with staff: 3
Training hours short: 4.75
Training hours recorded: 7.25
Training audit completion target: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 4 | Named in deficiency for insufficient annual training hours | |
| Staff 5 | Interviewed staff who stated she does not have required training hours | |
| Team Member Services Manager | HR Manager | Responsible for conducting audit of training records and overseeing plan of correction |
| Executive Director | Responsible for ensuring implementation and ongoing compliance with plan of correction |
Inspection Report
Monitoring
Census: 105
Deficiencies: 0
Jun 7, 2023
Visit Reason
The inspection was a monitoring visit to review various areas including administration, personnel, resident care, and emergency preparedness, as well as to observe medication administration and resident activities.
Findings
The inspector reviewed 8 records and conducted 3 interviews, observed residents during activities and lunch, and noted all facility self-reported incidents since the last inspection. No complaint was related to this visit.
Report Facts
Records reviewed: 8
Interviews conducted: 3
Inspection Report
Renewal
Census: 113
Deficiencies: 1
May 24, 2022
Visit Reason
The inspection was a renewal inspection conducted to review compliance with licensing standards and regulations for the assisted living facility.
Findings
The facility was found to have a deficiency related to missing diagnoses and conditions for medications administered to residents, based on resident record review and staff interviews.
Deficiencies (1)
| Description |
|---|
| Facility failed to have diagnoses and conditions for medications administered to residents in care. |
Report Facts
Census: 113
Records reviewed: 4
Records reviewed: 4
Interviews conducted: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Inspector | Current Inspector conducting the inspection |
| Executive Director | Named in plan of correction related to medication order deficiencies | |
| General Manager | Pharmacy personnel involved in plan of correction | |
| Director of Nursing | Responsible for ensuring implementation and ongoing compliance with plan of correction |
Inspection Report
Monitoring
Census: 86
Deficiencies: 3
Jan 28, 2021
Visit Reason
A monitoring inspection was initiated due to the state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to review compliance with applicable standards and laws.
Findings
The inspection identified non-compliance with several standards including incomplete documentation of physical examinations prior to admission, delayed development of preliminary plans of care, and false statements on sworn statements by staff.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that within 30 days preceding admission, a Physical Examination included documented allergies and reactions, and tuberculosis risk assessment. |
| Facility failed to ensure that on or within seven days prior to admission, a preliminary plan of care was developed to address resident needs. |
| 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. |
Report Facts
Resident records reviewed: 5
Staff records reviewed: 5
Staff #20 hire date: Jun 24, 2020
Staff #20 sworn statement date: Jun 4, 2020
Staff #20 criminal record date: Jun 17, 2020
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