18
Inspections
On record
11
With violations
Visits that cited something
7
Clean visits
Nothing cited
28
Violations cited
Individual findings
20
Standards cited
Distinct rules
7
Complaint visits
Prompted by a complaint
Sunrise of Fairfax was inspected 18 times between September 23, 2021 and February 13, 2026 by the Virginia Department of Social Services. 11 of those visits ended with violations cited and 7 with none. Across that history VDSS cited 28 violations under 20 distinct standards. 7 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.
Every inspection listed here is currently published on the VDSS site.
Provider Information
Facility type
Assisted Living Facility
License type
One Year
License expires
03/27/2027
Administrator
Jordan Kay
Licensing inspector
Marshall Massenberg
Inspector phone
(804) 543-5188
Approved for
Assisted Living · Special Care Unit · Non-Ambulatory
Inspection History
18Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.
February 13, 2026Inspection
Inspection dates
02/13/2026
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 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: Renewal
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/13/26 (9:15 AM - 5:00 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: 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: Three
Number of interviews conducted with staff: Four
Observations by licensing inspector: Meal, 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. 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
22VAC40-73-840-B
Based on record review and interview, the facility did not ensure that the documentation of examinations and immunizations of pets living in the assisted living facility, are maintained at the facility.
Evidence
- Pet records were reviewed during the inspection. The current rabies vaccination status was not present and unable to be obtained, during the inspection, for Pet #1 and Pet #2.
Plan of correction
With respect to the specific situation cited:
Residents did not experience negative outcomes due to outdated pet records in the community. Community contacted resident's POAs and obtained updated vaccination and examination records for Pet #1. Pet #2 is not a pet living at the community.
With respect to how the facility will identify situations with the potential for the identified concerns:
The Activities Volunteer Coordinator (AVC), and/or designee are conducting audits of the current documentation of examinations and immunizations of pets living in the community. Issues that may be identified will be addressed and resolved as needed.
The Activities Volunteer Coordinator (AVC), and/or designee are conducting monthly walking rounds of the community to ensure that the community has accurate documentation of examinations and immunizations of all pets living in the assisted living facility.
With respect to what systemic measures have bene put into place to address the citation:
Refresher training on the formal policy for maintaining pet records will be conducted. A checklist will be created to ensure all required documentation (e.g. rabies vaccination, routine exams) is updated annually or as required by law. The AVC and/or designee, will be responsible for verifying all pet documentation is current and filed appropriately. During resident move-in, pet vaccination and examination records will be collected and reviewed before the pet is allowed in the community.
All staff involved with resident pets will receive training on the new pet documentation policy, including where to store records, how to request updates from veterinarians, and the legal requirements for vaccinations.
AVC, and/or designee will review all pet files monthly to ensure documentation is complete and current. Any gaps will trigger immediately corrective action, including follow up with residents, POA or veterinarians.
In order to confirm that the process outlined above are sustained.
D. With respect to how the plan of correction will be monitored:
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. Tracking and trending will take place during QAPI meeting monthly for the next 2 months then quarterly thereafter to ensure that plan of correction is working.
22VAC40-73-640-A
Based on documentation, the facility did not implement a medication management plan to prevent the use of outdated medications and ensure that medications are filled and refilled in a timely manner to avoid missed dosages.
Evidence
- Resident #2's January and February medication administration records (MARs) were reviewed during the inspection. Resident #2's MAR states that her Dulera Inhalation Aerosol, ordered 6/6/24, was pending delivery on: 1/14/26 (evening dose); 1/16/26 (evening dose); 1/18/26 (morning dose); 1/21/26 (morning dose); 1/21/26 (evening dose); 1/22/26 (morning dose); 1/24/26 (evening dose). Resident #2's MAR states that her Pantoprazole, ordered 11/6/24, was pending delivery on: 1/23/26 (evening dose); 1/24/26 (morning dose); 1/24/26 (evening dose); 1/25/26 (morning dose); 1/26/26 (morning dose); 1/26/26 (evening dose); 1/27/26 (morning dose). Resident #2's MAR states that her Voltaren gel, ordered 2/15/24, was pending delivery on: 1/14/26 (evening dose); 1/15/26 (evening dose); 1/16/26 (evening dose); 1/18/26 (morning dose); 1/18/26 (evening dose); 1/19/26 (morning dose); 1/19/26 (evening dose); 1/20/26 (morning dose); 1/20/26 (evening dose); 1/21/26 (morning dose); 1/21/26 (evening dose); 1/22/26 (morning dose); 1/24/26 (evening dose), 1/25/26 (evening dose); 2/7/26 (evening dose); 2/8/26 (evening dose); 2/9/26 (morning dose); 2/9/26 (evening dose); 2/10/26 (morning dose).
Plan of correction
With respect to the specific situation cited: Residents did not experience any negative outcomes due to delay in medication administration and/or due delay in medication delivery.
With respect to how the facility will identify situations with the potential for the identified concerns:
The Resident Care Director (RCD), and/or designee are conducting audits of the electronic medical record (EMR) and medication carts for a representative sample of residents weekly for four (4) weeks to review adherence to the medication management plan, ensure medications are current, and confirm refills are requested in a timely manner.
Following this initial period, periodic audits will continue for a sample of residents twice monthly for two (2) months to monitor ongoing compliance. Observed issues will be documented, addressed as appropriate, and staff guidance or refresher education will be provided if indicated.
In addition, the RCD and/or designee will conduct weekly walking rounds for 30 days to observe medication cart organization and review medication administration documentation. After 30 days, rounds will continue twice monthly for two (2) months. Findings will be documented, and follow-up actions taken as needed to support safe medication practices.
Audit and round results will be shared with leadership and incorporated into the community's ongoing quality oversight process.
With Respect to what systemic measures have been put into place to address the citation:
Staff guidance of Refresher education will be provided based on findings.
In order to confirm that the processes outlined above are sustained:
With respect to how the plan of correction will be monitored:
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. Tracking and trending will take place during QAPI meeting monthly for the next 2 months then quarterly thereafter to ensure that plan of correction is working.
22VAC40-73-680-M
Based on record review and interview, the facility did not ensure that medications ordered for PRN administration are available and properly stored at the facility.
Evidence
- Resident #1's record contained a PRN order, dated 5/6/24, for Tylenol Extended Release tablets 650mg. Resident #1's PRN Tylenol Extended Release tablets were not present at the time of the medication cart inspection. Resident #1's record also contained a PRN order, dated 9/23/25, for Voltaren gel. Resident #1's PRN Voltaren gel was not present at the time of the medication cart inspection. Resident #2's record contained PRN orders for: Colace 100mg (ordered 10/16/24), Tylenol 325mg (ordered 6/29/23), Tylenol with Codeine 300-30mg (ordered 10/16/24), and Zofran 4mg (ordered 1/16/25). Resident #2's listed PRN medications were not present, at the time of the medication cart inspection. Facility staff confirmed that Resident #1 and Resident #2's PRN medication listed above were not present, at the time of the medication cart inspection.
Plan of correction
With respect to the specific situation cited:
Residents did not experience any negative outcomes due to PRN medication availability.
With respect to how the facility will identify situations with the potential for identified concerns:
The Resident Care Director (RCD), and/or designee are conducting audits of the electronic medical record (EMR) and medication carts for a representative sample of residents weekly for four (4) weeks to review adherence to the medication management plan, ensure medications are current, and confirm refills are requested in a timely manner.
Following this initial period. periodic audits will continue for a sample of residents twice monthly for two (2) months to monitor ongoing compliance. Observed issues will be documented, addressed as appropriate, and staff guidance or refresher education will be provided if indicated.
In addition, the RCD and/or designee will conduct weekly walking rounds for 30 days to observed medication cart organization and review medication administration documentation. After 30 days, rounds will continue twice monthly for two (2) months. Findings will be documented, and follow-up actions taken as needed to support safe medication practices.
Audit and round results will be shared with leadership and incorporated into the community's ongoing quality oversight process.
With respect to what systemic measures have been put into place to address the citation:
Staff guidance of Refresher education will be provided based on findings.
In order to confirm that the processes outlined above are sustained:
With Respect to how the plan of correction will be monitored:
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. Tracking and trending will take place during QAPI meeting monthly for the next 2 months then quarterly thereafter to ensure that plan of correction is working.
December 23, 2025Inspection
Inspection dates
12/23/2025, 02/13/2026
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: 12/23/25 (4:05 PM - 5:15 PM); 2/13/26 (9:15 AM - 5:00 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: 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: Four
Number of staff records reviewed: None
Number of interviews conducted with residents: Two
Number of interviews conducted with staff: One
Observations by licensing inspector:
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. 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.
Violations
22VAC40-73-70-C
Based on documentation, the facility did not submit a written report of each incident specified in the regulations to the regional licensing office within seven days from the date of the incident.
Evidence
- Incident information was provided to the licensing office on 12/11/25, and 12/15/25 with a full report to be provided. Written reports, that include all of the required information detailed in 22VAC40-73-70-C, were not provided to the regional licensing office within seven days of the dates of the incidents.
Plan of correction
Not published by VDSS.
22VAC40-73-460-D
Based on documentation, the facility did not ensure that supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.
Evidence
- Resident #1's record was observed during the inspection. Resident #1's record contained an Assessment of Serious Cognitive Impairment form, dated 7/26/24, that states that she has a serious cognitive impairment and that she is unable to recognize danger or protect her own safety and welfare. Facility correspondence indicated that Resident #1 eloped from the facility’s special care unit on 12/13/26 for roughly 30 minutes. Resident #1 was reported to have exited the unit and left the building through the facility's parking garage. After leaving the facility, Resident #1 sustained a head injury and was taken to the hospital. Additional details surrounding the incident were requested, but were not provided during the inspection.
Plan of correction
Not published by VDSS.
August 28, 2025Inspection
Inspection dates
08/28/2025, 09/11/2025, 9/19/2025
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: 8/28/25 (2:20 PM - 4:10 PM, 9/11/25 (11:45 AM - 11:50 AM, 9/19/25 (4:00 PM - 4:30 PM).
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-reported allegation was received by the VDSS licensing office on 8/28/25 in the area(s) of: Resident Care and Related Services
Number of residents present at the facility at the beginning of the inspection: 72
The licensing inspector completed a tour of the physical plant that included the building and grounds at the facility.
Number of resident records reviewed: One
Number of interviews conducted with residents: None
Number of interviews conducted with staff: Two
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.
August 19, 2025Complaint survey
Inspection dates
08/19/2025
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: 8/19/25 (2:50 PM - 4:25PM)
A complaint was received by the Fairfax Licensing Office on 8/15/25 regarding allegations in the area(s) of: Resident Care and Related Services
Number of residents present at the facility at the beginning of the inspection: 73
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: One
Number of interviews conducted with residents: None
Number of interviews conducted with staff: One
Additional Comments/Discussion:
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.
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.
August 19, 2025Inspection
Inspection dates
08/19/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 PERSONNEL
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: 8/19/25 (2:50 PM - 4:25 PM)
The Acknowledgement of Inspection form was signed and left at the facility for each date of the
inspection.
\lumber of residents present at the facility at the beginning of the inspection: 73
The licensing inspector completed a tour of the physical plant that included the building and
grounds at the facility.
Self-reported incident was received by the VDSS Division of Licensing in the area(s) of:
Personnel, Resident Care and Related Services
\lumber of resident records reviewed: One
\lumber of interviews conducted with residents: One
\lumber of interviews conducted with staff: One
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
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.massenberq@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
August 6, 2025Complaint survey
Inspection dates
08/06/2025
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: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/6/25 (9:05 AM - 2:25 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 7/25/25 regarding allegations in the areas of: Resident Care and Related Services; Safe, Secure, Environment
Number of resident records reviewed: Five
Number of interviews conducted with residents: Four
Number of interviews conducted with staff: Four
Observations by licensing inspector: Medication administration, meals, activities
The evidence gathered during the investigation supported the allegation of noncompliance.
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
22VAC40-73-660-A-1
Based on observation, the facility did not ensure that the medication storage area remains locked.
Evidence
- The facility's fourth-floor medication cart was observed to be unlocked and unattended at approximately 9:18 AM (8/6/25). The medication cart contained the medications for various residents that live on the facility's fourth floor. The third-floor wellness office was observed to be unlocked and unattended at approximately 10:26 AM. Several of Resident #5's medications were observed on a desk in the office.
Plan of correction
Not published by VDSS.
22VAC40-73-680-D
Based on record review and interview, the facility did not ensure that medications are administered in accordance with the physician’s instructions.
Evidence
- Resident #3's morning medication administration was observed during the inspection. Resident #3 reported that she did not receive her medication the previous evening (8/5/25). Resident #3's MAR (medication administration record) did not include documentation to indicate that she received her evening medications on 8/5/25: Cetirizine, Lidocaine patch, Nifedipine, Simvastatin, Trazadone, Dymista, Eliquis, Levetiracetam, Losartan Potassium, Senna-Docusate, Acetaminophen (9 PM administration), Hydralazine (7 PM administration). No progress notes were observed, during the inspection, that indicated that Resident #3 received her evening medication on 8/5/25. Resident #1's MAR indicates that his Vitamin D was not administered on 7/23/25. The medication was listed on the MAR as "pending delivery."
Plan of correction
Not published by VDSS.
22VAC40-73-680-I
Based on record review, the facility did not ensure that all of the required information is included on the medication administration record (MAR).
Evidence
- Resident #1's July and August MARs were reviewed during the inspection. Resident #1's MAR did not include documentation about the administration of his: Atorvastatin (8/5/25 – evening administration), Fluticasone (8/5/25 – evening administration), Melatonin (8/5/25 – evening administration), Metoprolol (8/5/25 – evening administration). No information was included on Resident #3's MAR to document the morning administration of the following medications on 7/6/25: Aspirin 81mg, Duloxetine, Isosorbide, Lasix, Magnesium, Miralax, Omeprazole, Oxybutynin, Potassium Chloride, Preservision, Vitamin D, Dymista, Eliquis, Levetiracetam, Losartan Potassium, Senna, Acetaminophen, Hydralazine.
Plan of correction
Not published by VDSS.
22VAC40-73-560-E
Based on observation and interview, it was determined that the facility did not
ensure that resident records are kept in a locked area.
Evidence
- At approximately 10:26 AM (8/6/25), the third-floor wellness office was observed to be open and unattended.
- Resident records are kept on the shelves in the staff office.
- Staff #3 was contacted in order to have the office locked.
Plan of correction
Not published by VDSS.
22VAC40-73-660-B
Based on observation and documentation, the facility did not ensure that medication storage is limited to an out-of-sight place in the rooms of those residents whose UAI (uniform assessment instrument) has indicated that the resident is capable of self-administering medication.
Evidence
- Acetaminophen and Vitamin E were observed near Resident #2's bed. Resident #2's physical examination, dated 4/29/24, states that the resident is not capable of self-administering medication. Resident #2's UAI, updated 10/22/24, states that the resident needs the assistance of medication aides and nurses for medication administration. Tums and Triamcinolone cream were observed near Resident #3's bed. Resident #3's UAI, updated 8/27/24, states that the resident needs the assistance of nurses and med techs for medication administration.
Plan of correction
Not published by VDSS.
July 21, 2025Complaint survey
Inspection dates
07/21/2025, 08/06/2025, 08/19/2025, 08/21/2025, 08/28/2025
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: 7/21/25 (4:10 PM - 5:15 PM), 8/6/25 (9:05 AM - 2:25 PM), 8/19/25 (2:50 PM - 4:25 PM), 8/21/25(3:05 PM - 4:06 PM), 8/28/25 (2:20 PM - 4:10 PM).
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. An exit meeting was conducted.
A complaint was received by VDSS Division of Licensing on 7/8/25 regarding an allegation in the area of: Resident Care and Related Services
Number of resident records reviewed: Four
Number of interviews conducted with staff: Eight
Observations by licensing inspector: Meals, Activities, Medication Administration
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
22VAC40-73-550-G
Based on record review, the facility did not ensure that resident rights are reviewed annually with each staff person.
Evidence
- The record for Staff #1, hired on 9/18/23, was observed during the inspection. Staff #1's record indicates that the most recent review of resident rights was completed in March 2024. Staff #1's most recent review of resident rights was more than a year old, when the inspection was initiated. Facility staff confirmed that Staff #1's most recent review of resident rights was more than a year old, when the inspection was initiated.
Plan of correction
A. With respect to the specific situation cited:
Staff #1 is completed required annual review for resident rights.
B. With respect to how the facility will identify situations with the potential for the identified concerns:
The Human Resource Coordinator (HRC) and/or designee are conducting audit of training records for current staff members to verify staff's annual review of Resident Rights is current. Issues that may be identified, will be addressed and resolved.
C. With respect to what systemic measures have been put into place to address the citation:
In order to confirm that the processes outlined above are sustained:
The Human Resource Coordinator and/or Designee will report results of the audits at Quarterly QAPI meeting. Issues that may be identified will be addressed and
resolved and refresher training initiated as needed.
D. With respect to how the plan of correction will be monitored:
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. Tracking and trending will take place during Quarterly QAPI meeting for the next 2 QAPI committee meetings.
July 21, 2025Complaint survey
Inspection dates
07/21/2025, 08/06/2025, 08/19/2025, 08/21/2025, 08/28/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 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: Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/21/25 (4:10 PM - 5:15 PM), 8/6/25 (9:05 AM - 2:25 PM), 8/19/25 (2:50 PM - 4:25 PM), 8/21/25(3:05 PM - 4:06 PM), 8/28/25 (2:20 PM - 4:10 PM).
A complaint was received by the Fairfax Licensing Office on 7/17/25 regarding allegations in the area(s) of: Staffing and 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: 72
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: None
Number of interviews conducted with residents: None
Number of interviews conducted with staff: Four
Additional Comments/Discussion:
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.
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.
April 23, 2025Inspection
Inspection dates
04/23/2025
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: 4/23/25 (8:45 AM - 6:45 PM)
Number of residents present at the facility at the beginning of the inspection: 69
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: Six
Number of interviews conducted with staff: Five
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-M
Based on observation and interview, the facility did not ensure that medications ordered for PRN administration are available and properly stored at the facility.
Evidence
- Resident #3's PRN Imodium and PRN Meclizine were not available for administration, at the time of the medication cart inspection. Resident #3 did have a package of Meclizine tablets, but it had expired on 1/31/25. Facility staff confirmed that Resident #3's PRN Imodium and PRN Meclizine were not available for administration, at the time of the medication cart inspection. Resident #5's PRN Albuterol and PRN Benzonatate were not present, at the time of the medication cart inspection. Facility staff confirmed that Resident #5's PRN Albuterol and PRN Benzonatate were not present, at the time of the medication cart inspection. Resident #6's PRN Guaifenesin and PRN Loperamide were not present, at the time of the medication cart inspection. Facility staff confirmed that Resident #6's PRN Guaifenesin and PRN Loperamide were not present, at the time of the medication cart inspection.
Plan of correction
Med cart audits were completed with focus on PRN medications. Expiration dates checked and refills ordered. Also, followed up on medications that needed to be discontinued by providers. Inservice was scheduled for medication techs and nurses on PRN medication procedures. Continued monthly medication cart audits to be performed.
22VAC40-73-660-B
Based on observation and documentation, the facility did not ensure that medication storage is limited to an out-of-sight place in the rooms of those residents whose UAI has indicated that the resident is capable of self-administering medication.
Evidence
- At approximately 9:35 AM Tylenol tablets and two capsules with a "TEVA 0812 50mg" imprint were observed in a room on the facility’s safe, secure neighborhood. The room was vacant, but it had previously been occupied by Residents #1 and #7. Resident #1's UAI, dated 4/24/24, states that the resident needs staff assistance for medication administration. Resident #7's UAI, dated 5/28/24, states that the resident needs staff assistance for medication administration.
Plan of correction
Apartment inspections to be completed upon move out to ensure nothing is left behind and apartment will be secured. The walk through will be conducted with family/POA and Sunrise representative.
22VAC40-73-450-E
Based on record review, the facility did not ensure that the individualized service plan (ISP) is signed by the administrator (or their designee), and by the resident or their legal representative.
Evidence
- Resident #1's record was reviewed during the inspection. Resident #1's record contained an ISP that was completed within the past year, but the last ISP that was signed by the resident (or his legal representative) was dated 6/10/23. Resident #2's record was reviewed during the inspection. Resident #2's record contained an ISP that was completed within the past year, but no ISP was observed in the resident record that was signed by the resident or her legal representative. Resident #4's record was reviewed during the inspection. Resident #4's record contained an ISP that was completed within the past year, but the last ISP that was signed by the resident (or her legal representative) was dated 12/18/23.
Plan of correction
ED/RCD/ALC/RC will ensure there is email documentation for any ISP where family/POA is unable to be onsite to sign. Also, the team will review monthly for compliance.
22VAC40-73-460-D
Based on record review, the facility did not provide supervision of resident schedules, care, and activities including attention to specialized needs, such as wandering from the premises.
Evidence
- Resident #1's record included a progress note, dated 2/3/25, that stated that the resident eloped from the facility's special care unit and exited to the building’s garage without staff supervision.
Plan of correction
Immediate and routine elopement drills. All staff in-service to review policy and procedures relating to specialized needs such as wandering and safety for those in the secured memory care neighborhood along with timely responses to any and all alerts.
22VAC40-73-640-A
Based on documentation and interview, the facility did not ensure that the medication management plan was implemented to ensure that each resident’s prescription medications are filled and refilled in a timely manner to avoid missed dosages.
Evidence
- Resident #8's April Medication Administration Record (MAR) was reviewed during the inspection. Resident #8's MAR included documentation that he did not receive his Hydrocortisone tablets (ordered 3/21/25) during the morning medication administration on 4/23/25. The MAR documented that the medication was "pending delivery." Facility staff confirmed that the medication was not present in the medication cart at the time of the inspection.
Plan of correction
Staff refresher training on timely refill requests. Any delay greater than 24 hours is to be escalated to the wellness nurse/RCD for follow up.
November 19, 2024Inspection
Inspection dates
11/19/2024, 11/21/2024
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 11/19/24 (2:30 PM - 5:30 PM), 11/21/24 (2:40 PM - 4:15 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 8/2/24, 8/13/24, and 11/6/24 in the area(s) of: Resident Care and Related Services
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: None
Number of interviews conducted with staff: Three
Observations by licensing inspector: Building and Grounds
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
22VAC40-73-460-D
Based on record review, the facility did not ensure that supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering of the premises.
Evidence
- Resident #2 was admitted to the facility's memory care unit on 8/1/24. Resident #2's record contained an Assessment of Serious Cognitive Impairment form, dated 7/26/24, that states that Resident #2 has a serious cognitive impairment with an inability to recognize danger or protect her own safety and welfare. On 8/2/24, progress notes indicate that Resident #2 was let out of the secure unit, as staff believed that she was a family member. Facility incident report states that Resident #2 exited the building's garage, walked around the building and entered the facility through the front door. Resident #2 was then returned to the memory care unit.
Plan of correction
An all-staff in-service was held to review policy and procedures relating to recognizing specialized needs such as wandering and safety for those in the secured memory care neighborhood. Routine elopement drills are practiced routinely.
22VAC40-73-310-H
Based on record review, the facility did not ensure that individuals: presenting imminent physical threat or danger to self or others.
Evidence
- Resident #1 was admitted to the facility on 8/1/24. Resident #1's physical examination form, dated 7/31/24, states that the resident "presents imminent physical threat or danger to self & others, requires continuous nursing care."
Plan of correction
ALC/RC/RCD/DOS will read and review physician's move in orders to ensure appropriate and safe placement of all residents.