Inspection Report
Monitoring
Census: 100
Deficiencies: 2
Oct 20, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at Vitality Living Arlington.
Findings
The inspection found non-compliance related to inadequate security monitoring of residents with serious cognitive impairments and failure to provide adequate supervision to prevent wandering from the premises. Violations were documented and a plan of correction was requested.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure doors leading to the outside have a system of security monitoring for residents with serious cognitive impairments. |
| Facility failed to provide supervision of resident schedules, care, and activities, including prevention of falls and wandering from the premises. |
Report Facts
Residents present: 100
Resident wandering distance: 0.3
Local temperature: 55
Resident records reviewed: 1
Staff records reviewed: 3
Staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Licensing Inspector | Current inspector conducting the inspection |
| Staff 1 | Interviewed staff member who reported on Resident 1 wandering and supervision | |
| Staff 3 | Staff member who reported Resident 1 wandering incident and interviewed regarding security monitoring |
Inspection Report
Monitoring
Census: 101
Deficiencies: 1
May 8, 2025
Visit Reason
The inspection was a monitoring visit to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with the regulation requiring that residents or their legal representatives be informed about sex offender registry information at admission and annually. Violations were documented and a plan of correction was requested.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that each resident or legal representative is fully informed about sex offender registry information at admission and annually. |
Report Facts
Number of residents present: 101
Number of resident records reviewed: 3
Number of staff records reviewed: 3
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 3
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 1
Feb 25, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2025-01-30 regarding allegations of physical abuse at the facility.
Findings
The investigation did not substantiate the complaint allegations of non-compliance. However, a violation unrelated to the complaint was identified regarding failure to document review of psychosocial and behavioral history to determine admission appropriateness.
Complaint Details
Complaint related to allegations of physical abuse received on 2025-01-30. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that the administrator or designee documents that the individual's psychosocial and behavioral history were reviewed and used to help determine the appropriateness of the admission. |
Report Facts
Residents present: 112
Resident records reviewed: 1
Staff records reviewed: 1
Resident interviews conducted: 1
Staff interviews conducted: 1
Random resident file audits: 3
Plan of correction completion date: Jun 30, 2025
Inspection Report
Renewal
Census: 119
Deficiencies: 13
Oct 17, 2024
Visit Reason
The inspection was a renewal inspection conducted on October 17 and 18, 2024, to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations including failure to obtain prior written approval for placement in a secure environment, failure to report major incidents timely, staff lacking current first aid certification, incomplete resident physical examinations, unsigned individualized service plans, medication management issues including missing and expired medications, and inadequate documentation of fire drills and resident council responses.
Deficiencies (13)
| Description |
|---|
| Failed to obtain written approval prior to placing a resident with serious cognitive impairment in a safe, secure environment. |
| Failed to report to the regional licensing office within 24 hours of major incidents affecting resident safety, including COVID-19 cases and a fall with injury. |
| Staff members did not maintain current first aid certification as required. |
| Resident physical examinations were incomplete, missing address, blood pressure, and general physical condition. |
| Individualized service plans were not signed and dated by residents or legal representatives. |
| Individualized service plans were not reviewed and updated at least annually or as needed for significant changes. |
| Menus for meals and snacks were not properly dated and posted in a conspicuous area. |
| Failed to ensure residents' prescription and over-the-counter medications were filled and refilled timely; presence of outdated and missing medications. |
| Medications and dietary supplements were started, changed, or discontinued without valid physician orders. |
| Resident records lacked signed physician or prescriber orders. |
| Durable Do Not Resuscitate (DNR) orders were not properly included in individualized service plans. |
| Failed to provide written responses to resident council recommendations prior to next meetings. |
| Fire drill records were incomplete, missing number of residents participating, special conditions, time to complete drills, and problems encountered. |
Report Facts
Number of residents present: 119
Number of resident records reviewed: 9
Number of staff records reviewed: 5
Number of resident interviews: 2
Number of staff interviews: 4
Expired medication bottles: 3
COVID-19 positive cases: 15
Dates of fire drills missing data: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Licensing Inspector | Conducted the inspection and interviews. |
| Nina Wilson | Licensing Inspector | Contact person for questions about VDSS Licensing Programs. |
| Staff 4 | Staff member lacking current first aid certification. | |
| Staff 5 | First Aid Instructor | Staff member with expired first aid certification. |
| Staff 6 | Staff interviewed regarding COVID reporting, medication, and documentation issues. | |
| Staff 7 | Staff interviewed regarding medication availability and COVID line list. | |
| Staff 8 | Staff interviewed regarding incomplete physical examination forms. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of delayed response to resident call bell alerts.
Findings
The investigation found that staff failed to ensure prompt response to resident needs via call bell alerts, with documented delays in response times. A violation notice was issued and a plan of correction was proposed to improve call bell response times.
Complaint Details
The complaint was substantiated in part; evidence supported some but not all allegations of non-compliance related to delayed call bell response times.
Deficiencies (1)
| Description |
|---|
| Staff failed to ensure prompt response to resident needs via call bell alert. |
Report Facts
Resident records reviewed: 6
Staff records reviewed: 4
Resident interviews conducted: 1
Staff interviews conducted: 1
Call bell response delay example: 35
Call bell response delay example: 72
Call bell response delay example: 149
Inspection Report
Monitoring
Census: 144
Deficiencies: 5
Jun 17, 2024
Visit Reason
The inspection was a monitoring inspection conducted to review compliance with applicable regulations and standards at the assisted living facility.
Findings
The inspection identified multiple violations including incomplete physical examination records, outdated resident agreements, lack of documented emergency preparedness training, incomplete first aid kits, and failure to perform monthly first aid kit checks.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure that a person shall have a physical examination by an independent physician with all required components on file. |
| Facility failed to ensure that resident agreements are updated, dated, and signed by all required parties when changes occur. |
| Facility failed to review and document the emergency preparedness plan annually or more often as needed. |
| Facility failed to ensure a complete first aid kit is on hand, missing items such as plastic bags, disposable blankets, flashlight, batteries, thermometer, or breathing barriers. |
| Facility failed to ensure monthly checks and documentation of first aid kits are completed. |
Report Facts
Number of residents present: 144
Number of resident records reviewed: 4
Number of staff records reviewed: 4
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Licensing Inspector | Conducted the inspection and is the contact for questions |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 14, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to Resident Care and Related Services at Vitality Living Arlington.
Findings
The complaint was investigated and determined to be not valid.
Complaint Details
Complaint was determined not valid.
Inspection Report
Monitoring
Census: 103
Deficiencies: 1
Aug 9, 2023
Visit Reason
The inspection was a monitoring visit conducted on August 9, 2023, to review resident care and related services following multiple self-reports regarding allegations in these areas.
Findings
The investigation did not substantiate the self-reported non-compliance; however, violations unrelated to the self-report were identified, including failure to include Do Not Resuscitate (DNR) orders in individualized service plans (ISPs) for certain residents.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that Do Not Resuscitate (DNR) Orders were included in the individualized service plans (ISPs) for Residents #2 and #4. |
Report Facts
Number of residents present: 103
Number of resident records reviewed: 5
Number of staff records reviewed: 1
Number of staff interviews conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Eddy | Licensing Inspector | Contact person for questions regarding the inspection |
| Alexandra Roberts | Current Inspector | Licensing inspector on-site during the inspection |
| Director of Wellness | Obtained DNR orders and updated ISPs for Residents #2 and #4 as part of the plan of correction |
Inspection Report
Monitoring
Census: 106
Deficiencies: 0
Nov 8, 2022
Visit Reason
A focused monitoring inspection was conducted to ensure correction of previous B-2 violations and to investigate a self-reported incident regarding allegations in resident care and admission, retention, and discharge of residents.
Findings
The inspection found no violations with applicable standards or laws related to the previous B-2 violation and did not support the self-report of non-compliance. The inspection findings will be posted publicly.
Report Facts
Number of resident records reviewed: 8
Number of residents present: 106
Inspection Report
Renewal
Census: 108
Deficiencies: 1
Oct 6, 2022
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws prior to the expiration of the facility's current license.
Findings
The inspection found non-compliance related to medication administration timing, specifically that medications were not administered within the required time frame around the scheduled dosing times.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that medications were administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, as evidenced by delayed administration of six medications to a resident. |
Report Facts
Number of residents present: 108
Number of resident records reviewed: 12
Number of staff records reviewed: 5
Number of interviews conducted with staff: 1
Number of medications scheduled at 9 am not administered on time: 6
Total medications scheduled at 9 am for Resident #5: 15
Date for completion of audits: Oct 21, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Licensing Inspector | Conducted the inspection and observed medication administration |
| Staff #2 | Observed administering medications to Resident #5 and reported medication administration times |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 0
Aug 5, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2022-07-12 regarding allegations related to building and grounds at the facility.
Findings
The licensing inspector toured the physical plant including the building and grounds. The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.
Complaint Details
Complaint was related to building and grounds. The investigation did not substantiate the allegations of non-compliance.
Report Facts
Number of residents present: 106
Number of staff interviews: 2
Inspection Report
Monitoring
Census: 105
Deficiencies: 4
Jun 21, 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 identified multiple violations related to staff records, including missing criminal record reports, lack of current first aid certification, missing Do Not Resuscitate (DNR) orders on individual service plans, and incomplete sworn statements or affirmations for employment applicants.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure original criminal record reports were maintained in staff records for Staff #4 and Staff #5. |
| Facility failed to ensure direct care staff maintained current first aid certification for Staff #1, #3, and #5. |
| Facility failed to include Do Not Resuscitate (DNR) orders on individual service plans for Resident #2, #6, #7, and #8. |
| Facility failed to ensure sworn statement or affirmation was completed for employment applicants Staff #8, #12, #19, #37, #39, #41, #42, and #43. |
Report Facts
Number of residents present: 105
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of resident interviews conducted: 4
Number of staff interviews conducted: 1
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 22, 2021
Visit Reason
The inspection was conducted as a complaint investigation regarding staff qualifications, specifically the licensing status of the Assisted Living Facility Administrator.
Findings
The complaint was substantiated with a violation cited for failure to ensure the administrator held a valid assisted living facility administrator license, which had expired on 03/31/2021. The license was renewed immediately upon notification.
Complaint Details
The complaint was deemed valid related to Standard 22VAC40-73-140. The violation was corrected during the exit interview.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that the administrator shall be licensed as an assisted living facility administrator by the Virginia Board of Long-Term Care Administrators. |
Report Facts
License expiration date: Mar 31, 2021
Inspection dates: 2
Plan of correction submission timeframe: 10
Inspection Report
Monitoring
Deficiencies: 0
Apr 20, 2021
Visit Reason
A monitoring inspection was initiated due to a self-reported incident regarding allegations of personnel exploitation of a resident, conducted using an alternate remote protocol due to a state of emergency health pandemic.
Findings
The inspection determined no violations with applicable standards or law, and no violations were issued.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 12, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding buildings and grounds at the facility, conducted remotely due to a state of emergency health pandemic.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. Any violations unrelated to the complaint are documented separately on the violation notice.
Complaint Details
A complaint was received concerning buildings and grounds. The administrator was contacted by telephone and documentation was requested via email. The evidence did not substantiate the complaint allegations.
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