Arleigh Burke Pavilion

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 61/2/26 (8:30 AM - 3:00 PM) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 19 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Two Number of staff records reviewed: Two Number of interviews conducted with residents: Three Number of interviews conducted with staff: Three Observations by licensing inspector: Meals, Medication Administration, Activities Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.

Documentation was discussed with the provider.

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/10/25 (8:30 AM - 2:00 PM). Number of residents present at the facility at the beginning of the inspection: 19 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Two Number of interviews conducted with residents: Three Number of interviews conducted with staff: Two Observations by licensing inspector: lunch, medication administration, activities An exit meeting was held. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/21/25 (4:30 PM - 4:45 PM) Facility documentation was reviewed in the area of: Administration and Administrative Services Number of interviews conducted with staff: One Observations by licensing inspector: Facility documentation No violations were cited during the inspection. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov.

Date of Inspection: July 24, 2023 Type of Inspection: Renewal inspection Census 18 Number of records reviewed and interviews conducted- 6 records, 3 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The LI observed residents eating lunch and participating in activity programs. If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov.

Date of Inspection: May 31, 2023 Type of Inspection: Monitoring inspection Census 18 Number of records reviewed and interviews conducted- 8 records, 5 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The LI observed residents eating lunch and LI also observed medications being administered to residents. If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov.

Date of Inspection: May 25 and 27, 2022 Type of Inspection: Monitoring Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 20 Number of records reviewed and interviews conducted- 3 resident records and 3 staff records, 4 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during lunch and activities. The Licensing Inspector reviewed the following documents during the inspection: fire drills, healthcare oversight, dietician report, activity calendar and emergency preparedness drills. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 6/01/2021 and concluded on 6/02/2021. The administrator was contacted by telephone for an entrance interview to initiate the inspection. The administrator reported that the current census was 19. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed two resident records and two staff records. Criminal record checks and sworn statements of all staff hired since last inspection and other documentation submitted by the facility was reviewed to ensure documentation was complete. Exit interview was conducted with the administrator and the director of nursing on 6/14/2021. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again, 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s), and 4) date that that plan of correction will be completed. Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.