15
Inspections
On record
7
With violations
Visits that cited something
8
Clean visits
Nothing cited
13
Violations cited
Individual findings
9
Standards cited
Distinct rules
5
Complaint visits
Prompted by a complaint
Sunrise at Silas Burke House was inspected 15 times between January 4, 2021 and May 12, 2026 by the Virginia Department of Social Services. 7 of those visits ended with violations cited and 8 with none. Across that history VDSS cited 13 violations under 9 distinct standards. 5 inspections were prompted by a complaint.
A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.
VDSS publishes inspections on a rolling window. 14 of these 15 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.
Provider Information
Facility type
Assisted Living Facility
License type
Three Year
License expires
03/31/2027
Administrator
Andres Ulloa
Licensing inspector
Marshall Massenberg
Inspector phone
(804) 543-5188
Approved for
Assisted Living
Inspection History
15Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.
May 12, 2026Complaint survey
Inspection dates
05/12/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2 GENERAL PROVISIONS63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/12/26 (4:30 PM - 5:00 PM).
A complaint was received by the Fairfax Licensing Office on 4/30/26 regarding: Resident Care and Related Services
Number of residents present at the facility at the beginning of the inspection: 82
Number of resident records reviewed: One
Number of interviews conducted with staff: One
Number of interviews conducted with residents: None
Observations by licensing inspector: N/A
Additional Comments/Discussion: N/A
An exit meeting was conducted.
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.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
May 5, 2026Inspection
Inspection dates
05/05/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUNDS63.2 GENERAL PROVISIONS63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS
Technical assistance
Documentation was discussed with the provider.
Comments
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: 5/5/26 (1:40 PM - 5:00 PM).
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Self-Reported incidents were received by VDSS Division of Licensing on 4/3/26 and 4/15 regarding allegations in the area(s) of: Administration and Administrative Services, Personnel, Staffing and Supervision, Resident Care and Related Services.
Number of residents present at the facility at the beginning of the inspection: 82
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: One
Number of interviews conducted with residents: Two
Number of interviews conducted with staff: Three
Observations by licensing inspector: N/A
Additional Comments/Discussion: N/A
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can be found on the violation notice. 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.
Violations
22VAC40-80-160-D
Based on interview, the facility did not at all times afford the department's representative reasonable opportunity to inspect all of the facility's or agency's buildings, books, and records. Records that contain confidential proprietary information furnished to the department pursuant to this section shall be exempt from disclosure pursuant to subdivision 4 of § 2.2-3705.5 of the Code of Virginia.
Evidence
- Staff #1 reported that a statement was created after Resident #1 made an allegation. The statement was requested during the inspection. Staff #1 refused to provide the information and stated that it was "confidential."
Plan of correction
Not published by VDSS.
March 10, 2026Inspection
Inspection dates
03/10/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Technical assistance
Documentation was discussed with the provider.
Comments
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: 3/10/26 (8:45 AM - 7 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: 78
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: Six
Number of staff records reviewed: Three
Number of interviews conducted with residents: Four
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.
Violations
22VAC40-73-680-D
Based on record review, the facility did not ensure that medications are administered in accordance with the physician's instructions.
Evidence
- Resident #1's Losartan Potassium order, dated 2/27/25, calls for the medication to be held if the resident's systolic blood pressure (SBP) is less than 120 or her pulse is less than 60. Resident #1's February and March Medication Administration Records (MARs) indicated that Resident #1's Losartan Potassium was administered, when her SBP was less than 120 or her pulse was less than 60 on the following dates: 2/9/26: SBP= 109 (Pulse= 67) 2/14/26: SBP= 113 (Pulse= 71) 2/27/26: SBP= 118 (Pulse= 68) 3/4/36: SBP= 114 (Pulse= 65) 3/6/26: SBP= 111 (Pulse= 69) Resident #1's MAR indicated that her Losartan was held on 3/1/26, when her SPB was 120 and her pulse was measured to be 73. Resident #1's MAR contained a notation on 3/1/26 that indicated that her vitals were outside the parameters.
Plan of correction
Resident #1 did not experience any negative outcomes. Physician was notified.
Resident Care Director (RCD) completed refresher training with the current wellness team regarding current medication with parameters and procedures to follow to administer medications in accordance with the physician's orders.
RCD conducted EMAR audits to physician's orders to confirm parameters are in accordance with the physician's order.
The RCD or designee will continue to conduct EMAR audits to physician's orders weekly for 4 weeks and biweekly for 4 weeks to confirm parameters in accordance with physician's orders.
RCD will conduct an unannounced medication observation to confirm that medications are administered in accordance with physician's orders.
During and at the end of two months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results and determine if additional focus or action is warranted.
The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-680-M
Based on record review and interview, the facility did not ensure that PRN medications are available and properly stored at the facility.
Evidence
- Resident #1's PRN Imodium (ordered 10/1/24) and Lidocaine patch (ordered 11/26/24) were not present at the time of the medication cart inspection. Resident #7's PRN Tylenol (ordered 12/4/24) was not present at the time of the medication cart inspection. Resident #8's PRN Tylenol (ordered 8/23/25) was not present at the time of the medication cart inspection. Facility staff confirmed that the above PRN medications for Residents #1, #7, and #8 were not present at the time of the medication cart inspection.
Plan of correction
Resident #1, #7, and #8 did not experience any negative outcomes due to not having a prn medication available. PRN medications were reordered and are now available in the community.
RCD conducted refresher training with the specific Medication Technician(s) regarding reordering medications timely.
Refresher training was conducted by RCD on the importance of reordering medications timely with the current wellness team.
RCD or designee will review prn medications weekly to confirm that medications are available for up to 3 months.
RCD will periodically audit randomly from listed weekly med cart audit list for prn medications.
The results of the audits will be presented at QAPI quarterly for up to 3 months.
The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
December 17, 2025Inspection
Inspection dates
12/17/2025; 03/10/2026
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
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: 12/17/25; 3/10/26
Self-reported incidents were received by VDSS Division of Licensing regarding: Resident Care and Related Services
Number of resident records reviewed: One
Number of interviews conducted with staff: Four
Number of interviews conducted with residents: One
Observations by licensing inspector:
Additional Comments/Discussion: N/A
An exit meeting was conducted.
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
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
November 5, 2025Inspection
Inspection dates
11/05/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
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: 11/05/25 (1:10 PM - 2:00 PM)
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
Self-reported incidents were received by the Fairfax Licensing Office in the area(s) of: Resident Care and Related Services.
Number of resident records reviewed: Four
Staff Records reviewed: One
Number of interviews conducted with residents: One
Number of interviews conducted with staff: One
Observations by licensing inspector: Facility documents
The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. 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.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
April 16, 2025Inspection
Inspection dates
04/16/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 - SUBJECTIVITY63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Technical assistance
Documentation was discussed with the provider.
Comments
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: 4/16/25 (8:45 AM - 6:45 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: 67
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: Six
Number of interviews conducted with residents: Four
Number of interviews conducted with staff: Two
Observations by licensing inspector: Meals, medication administration, activities
Additional Comments/Discussion:
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.
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 the 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.
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.
Violations
22VAC40-73-680-D
Based on observation and record review, the facility did not ensure that medication was administered in accordance with the physician’s instructions.
Evidence
- Resident #1's medication administration record (MAR) was reviewed during the inspection. Resident #1's MAR documented that her Lisinopril was not administered on the following dates due to her vitals being outside of parameters: 3/26/25, 4/6/25, 4/13/25, 4/15/25. Resident #1's Lisinopril order calls for the medication to be held if the resident's Systolic Blood Pressure (SBP) is less than 100. Resident #1's SBP readings were listed as being: 3/26/25 (101), 4/6/25 (155), 4/13/25 (155), and 4/15/25 (133). The morning medication administration, for Resident #2, was observed during the inspection. The resident's medications were placed in a pill cup and the medication cart was locked. Before the medications were administered to Resident #2, the LI inquired about the resident's Aspirin. Only one Aspirin 81mg tablet was included in Resident #2's pill cup. Resident #2's record contained an order, dated 4/5/25, that calls for her to receive four tablets of Aspirin 81mg, during the morning medication administration.
Plan of correction
Resident #1 and Resident #2 did not experience any negative outcome. Physicians were notified.
Resident Care Director (RCD) completed a refresher training with the current wellness team regarding current medication with parameters and procedures to follow to administer medications in accordance with the physician's orders. Resident Care Director (RCD) conducted EMAR audits to physician's orders to confirm parameters are in accordance with the physician's order.
The RCD or designee will continue to conduct EMAR audits to physician's orders weekly for 4 weeks and biweekly for 4 weeks to confirm parameters in accordance with physician's orders. RCD will conduct an unannounced medication observation to confirm that medications are administered in accordance with physician's orders.
During and at the end of two months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results and determine if additional focus or action is warranted. The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-250-D
Based on record review and interview, the facility did not ensure that each staff member annually submits the results of a tuberculosis risk assessment (documenting that the individual is free of tuberculosis in a communicable form).
Evidence
- The staff records of Staff #1 (hired 5/4/12) and Staff #2 (hired 4/5/19) were reviewed during the inspection. The most recent tuberculosis risk assessment included in the record for Staff #2 was dated 3/28/23. No tuberculosis risk assessment was provided, during the inspection, for Staff #1. Facility staff confirmed that the annual tuberculosis risk assessments were not present, during the inspection, for Staff #1 and Staff #2.
Plan of correction
Employees #1 and #2 have both had their annual tuberculosis (TB) screenings completed.
Human Resource Coordinator (HRC) conducted an audit of employee's annual TB screenings to verify current employees have them completed.
The Executive Director (ED) or designee will conduct an audit of annual TB screenings to verify completion monthly for up to 3 months.
The results of audits will be presented to the Quality Assurance and Performance Improvement (QAPI) Committee quarterly for up to 3 months
The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-650-F
Based on record review, the facility did not ensure that new orders were obtained for all medications and treatments, prior to a resident's return to the facility following a hospital admission.
Evidence
- Resident #3's record contained documentation of a hospital admission on 3/28/25. The discharge instructions call for the resident to continue taking two Acetaminophen 500mg tablets every eight hours. Resident #3's MARs indicate that the resident received 975mg of Acetaminophen three times per day, before and after the hospital admission. Resident #3's record contained an Acetaminophen order, dated 3/4/25, that called for the resident to receive 975mg of Acetaminophen three times per day. No documentation was provided, during the inspection, to indicate that new orders were received for Resident #3's medication after he was admitted to the hospital.
Plan of correction
Resident did not experience any negative outcome. Discharge summary was reviewed by physician and changes were made based on plan of care and resident's preference.
Audit was completed by Resident Care Director (RCD) for current returning resident to confirm that recommendations on discharge summaries were reviewed by physician and recommendations were addressed.
Re-education was provided to the Wellness Nurse (WN) regarding the utilization of the hospital discharge summary for changes in medication or treatments.
Resident Care Director or designee will contact physician regarding changes on discharge summary and responses will be documented and implemented.
The Resident Care Director (RCD) or designee will review discharge summary weekly for 4 weeks and biweekly for 4 weeks. Issues identified will be resolved. The results of the audits will be presented at (QAPI) quarterly for 2 quarters during the end of the 2nd quarter, the QAPI committee will evaluate the result of the audits and determine if additional focus or action is warranted. The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-680-M
Based on observation and interview, the facility did not ensure that PRN medications were available and properly stored at the facility.
Evidence
- Resident #1's PRN Meclizine, Metamucil, and Guaifenesin were not present, at the time of the medication cart inspection. Facility staff confirmed that the listed PRN medications were not present, at the time of the medication cart inspection.
Plan of correction
Resident #1 did not experience any negative outcomes due to not having a prn medication available. PRN medications were reordered and are now available in the community.
RCD conducted refresher training with the specific Medication Technician regarding reordering medications timely.
Refresher training was conducted by Resident Care Director on the importance of reordering medications timely with the current wellness team.
March 4, 2025Complaint survey
Inspection dates
03/04/2025, 03/06/2025, 03/31/2025; 04/16/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/4/25 (2:15 PM - 4:45 PM), 3/6/25 (10 AM - 2 PM), 3/31/25 (10 AM - 11:35 AM), 4/16/25 (8:45 AM - 6:45 PM).
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Complaints were received by VDSS Division of Licensing on 2/14/25 and 3/31/25 regarding allegations in the area(s) of: Resident Care and Related Services and Resident Accommodations and Related Provisions
Number of residents present at the facility at the beginning of the inspection: 75
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: Three
Number of interviews conducted with residents: Three
Number of interviews conducted with staff: Three
Observations by licensing inspector: Meal
Additional Comments/Discussion:
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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.
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 the 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.
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
Violations
22VAC40-73-470-A
Based on record review, the facility did not ensure that the health care service needs of residents are met.
Evidence
- Resident #1’s record included an order, dated 6/4/24, for her blood pressure to be checked twice daily. The resident record also included an order, dated 1/14/25, to discontinue the blood pressure checks. Resident #1’s record indicated the following blood pressure history: June (19 blood pressure checks); July (20 blood pressure checks); August (15 blood pressure checks); September (11 blood pressure checks); October (five blood pressure checks); November (one blood pressure checks); December (five blood pressure checks); January (three blood pressure checks).
Plan of correction
Resident #1 did not experience any negative outcome. Physician was notified and supplemental blood pressure order was discontinued by physician.
RCD audited medication orders requiring supplementation documentation, supplementation order was added as required by the physician's order Refresher training was provided by Resident Care Director (RCD) to current Wellness Nurse to properly transcribe order as written by the physician.
Resident Care Director (RCD) or designee will continue to audit resident records to confirm medications are transcribed correctly weekly up to 3 months. Re-educate Medication Technician to notify Resident Care Director (RCD) or designee if medications are transcribed incorrectly.
The results of the audits will be presented at (QAPI) quarterly for up to 3 months.
The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
March 4, 2025Inspection
Inspection dates
03/04/2025, 03/06/2025, 03/31/2025, 04/16/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
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: 3/4/25 (2:15 PM - 4:45 PM), 3/6/25 (10 AM - 2 PM), 3/31/25 (10 AM - 11:35 AM), 4/16/25 (8:45 AM - 6:45 PM).
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
Self-reported incidents were received by VDSS Division of Licensing on: 2/14/25, 2/24/25, 2/28/25, 3/19/25, 3/25/25, and 4/7/25 regarding allegations in the area(s) of: Resident Care and Related Services, Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments
Number of residents present at the facility at the beginning of the inspection: 75
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: Seven
Number of interviews conducted with residents: Three
Number of interviews conducted with staff: Two
Observations by licensing inspector: Meal
Additional Comments/Discussion:
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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.
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 the 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.
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
Violations
22VAC40-73-640-A
Based on documentation, the facility did not ensure that the medication management plan was implemented to accurately transcribe medication administration records (MARs) within 24 hours of the receipt of a new order.
Evidence
- Resident #1's record contained an order for Vitron-C, dated 1/20/25. The Vitron-C order, for Resident #1, was added to the MAR of Resident #2. Vitron-C was not added to Resident #1's MAR until 2/18/25.
Plan of correction
Resident #1 did not experience any negative outcomes due to having his physician having a signed order. Physician was notified and order was discontinued.
Resident Care Director or designee conducted audit to confirm that orders transcribed is in accordance with physician orders.
The Resident Care Director (RCD) and/or designee will continue to audit transcribed orders to confirm that orders transcribed are in accordance with physician orders weekly for 4 weeks and monthly for 2 months.
The results of the audits will be presented at (QAPI) quarterly for up to 3 months.
The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-650-A
Based on documentation, the facility failed to ensure that no medication or dietary supplement is started, changed, or discontinued by the facility without a valid order from a physician or prescriber.
Evidence
- Resident #2's MAR indicates that she was administered Vitron-C from 1/21/25 until 2/6/25. Resident #2 did not have an order for Vitron-C to be administered.
Plan of correction
Resident #2 did not experience any negative outcomes due to not having his medication as ordered by the physician. Physician was notified and physician order was transcribed as ordered by the physician.
Resident Care Director or designee conducted audit to confirm that orders transcribed is in accordance with physician orders.
The Resident Care Director (RCD) and/or designee will continue to audit transcribed orders to confirm that orders transcribed are in accordance with physician orders weekly for 4 weeks and monthly for 2 months.
The results of the audits will be presented at (QAPI) quarterly for up to 3 months.
The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
January 28, 2025Complaint survey
Inspection dates
01/28/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/28/25 (2:30 PM - 3:30 PM)
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by the Fairfax Licensing Office on 12/18/24 in the area of: Resident Care and Related Services.
Number of resident records reviewed: Two
Staff Records reviewed: None
Number of interviews conducted with residents: Two
Number of interviews conducted with staff: One
Observations by licensing inspector: Facility documents
The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. 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.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
October 29, 2024Complaint survey
Inspection dates
10/29/2024, 10/30/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Documentation was discussed with the provider.
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/29/24 (4:00 PM - 7:15 PM), 10/30/24 (2:30 PM - 4:25 PM)
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by VDSS Division of Licensing on 9/13/24 regarding allegations in the areas of: Resident Care and Related Services.
Number of resident records reviewed: One
Number of interviews conducted with residents: None
Number of interviews conducted with staff: One
Observations by licensing inspector: Resident Record
The evidence gathered during the investigation supported the allegation of non-compliance in the area of: Resident Care and Related Services.
A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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. 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 the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with 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.
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
Violations
22VAC40-73-650-A
Based on record review, 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.
Evidence
- Resident #1's closed record contained an order for Premarin cream, dated 4/2/24, that called for the resident to receive 0.5g of cream administered daily for 2 weeks, then reduce to twice weekly. Resident #1's April medication administration record (MAR) indicates that she self-administered the cream on 4/3/24 and 4/4/24. The medication was listed as "medication pending delivery" on 4/5/24 and 4/6/24. Facility staff began administering 0.5g of cream daily from 4/7/24 through 4/18/24, with the exception of 4/14/24 and 4/17/24 (when the resident was noted to be sleeping). Facility staff began administering 0.5g of Premarin cream two times per day beginning on 4/20/24 and ending on 4/30/24. No physician's order was included in Resident #1's record for the administration of 0.5g of Premarin cream two times per day.
Plan of correction
A) With respect to the specific resident/situation cited:
Resident 1 did not experience any negative outcomes due to not having a signed order.
B) With respect to how the facility will identify residents/situations with the potential for the identified concerns:
Re-education was provided to Wellness Nurse (WN) regarding the utilization of the physician order form for any medication, treatment or procedure and the need for the physician to sign off within 14 days of the order.
C) With respect to what systemic measures have been put into place to address the stated concern:
The RCD or designee will conduct an audit of Electronic Health Records to verify valid prescription orders monthly for up to 3 months. The results of the audits will be presented to the QAPI Committee quarterly for up to 3 months.
D) With respect to how the plan of correction will be monitored:
POC and monitoring results are reviewed and evaluated by the ED and coordinators at the QAPI meeting for quarter four and quarter one to ensure it is still effective. If it is no longer effective, it will be amended and a new POC will be implemented and monitored to ensure the violation does not occur again.
22VAC40-73-470-A
Based on record review, the facility did not ensure that the health care service needs of residents are met.
Evidence
- Resident #1's closed record was observed during the inspection.
- Resident #1's closed record included a hospital discharge summary, dated 3/28/24. The discharge instructions stated that Resident #1 needed to schedule an appointment with Inova Medical Group Urology as soon as possible for a visit in 1 month(s). The instructions also listed a time and date for a new patient appointment at Inova Medical Group Urology (4/19/24 - 1:45 PM).
- Resident record contained a physician/practitioner progress note, dated 4/2/24, that states "Patient was self administering medications. It is unclear if she administered correctly. She notes diarrhea that occurred for 2 weeks. Went to ED last week d/t diarrhea. Found to have proctitis. Recommend GI f/u."
- Physician/practitioner note, dated 6/18/24, states "After hospital visit 4/2024 she was found to have proctitis on CT scan. She was supposed to follow up with GI, however reports this was never done."
- Hospital record, dated 6/24/24, indicates that Resident #1 returned to the hospital on 6/19/24. The hospital's discharge medication list included Vancomycin for Clostridium Difficile Infection.
Plan of correction
A) With respect to the specific resident/situation cited:
Resident 1 did not experience any negative outcomes due to not attending her scheduled GI consult. Resident was seen by the Nurse Practitioner (NP) the following day after being discharged back to the community and had a follow up visit from the NP roughly two weeks later.
B) With respect to how the facility will identify residents/situations with the potential for the identified concerns:
Resident Care Director (RCD) or designee conducted an audit of recent resident records discharged back to the community to identify consults. Re-education was provided to all wellness staff and care coordinators regarding procedures for discharge paperwork. Procedures are to collect discharge paperwork upon discharge back to the community and contact responsible party to review follow up instructions for responsible party to schedule follow up appointments and transportation.
C) With respect to what systemic measures have been put into place to address the stated concern:
The RCD or designee will continue to conduct audits of discharge paperwork on residents being discharged back to the community monthly for up to 3 months to confirm consults. The results of the audits will be presented to the Quality Assurance and Performance Improvement (QAPI) Committee quarterly for up to 3 months.
D) With respect to how the plan of correction will be monitored:
Plan of Correction (POC) and monitoring results are reviewed and evaluated by the Executive Director (ED) and coordinators at the QAPI meeting for quarter four and quarter one to ensure it is still effective. If it is no longer effective, it will be amended and a new POC will be implemented and monitored to ensure the violation does not occur again.