Virginia DSS · Assisted Living Facility

Sunrise of Alexandria

📍 3520 Duke Street, Alexandria, VA, 22304

ID 50165One Year licenseActive
9
Inspections
On record
3
With violations
Visits that cited something
6
Clean visits
Nothing cited
11
Violations cited
Individual findings
10
Standards cited
Distinct rules
4
Complaint visits
Prompted by a complaint

Sunrise of Alexandria was inspected 9 times between September 11, 2023 and March 10, 2026 by the Virginia Department of Social Services. 3 of those visits ended with violations cited and 6 with none. Across that history VDSS cited 11 violations under 10 distinct standards. 4 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
03/20/2027
Administrator
Arin Burrell-Duru
Licensing inspector
Ishmel Paige
Inspector phone
(804) 963-0360
Approved for
Non-Ambulatory · Special Care Unit · Assisted Living

Inspection History

9

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

March 10, 2026Inspection7 violations
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 GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Technical assistance
Licensing inspector (LI) reviewed the following the standards with the facilities: 22VAC40-73-45, 22VAC40-73-280, 22VAC40-73-325, 22VAC40-73-490, 22VAC40-73-970, and 22VAC40-73-1110.
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: 03/10/2026 Time in: 10:19 AM Time out: 6:36 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: 76 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 6 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 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. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
22VAC40-73-950-E
Based on record review and staff interview, the facility failed to develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual’s respective responsibilities. The review should be documented by signing and dating.
Evidence
  1. The emergency preparedness and response plan was reviewed and documented as completed on 02/26/2025 with only residents signing and dating. Upon request, the facility was unable to provide a semi-annual review with all staff, residents, and volunteers.
  2. During the onsite inspection, 03/10/2026, staff 8 confirmed that the emergency preparedness and response plan was not documented as reviewed by all staff, residents, and volunteers signing and dating semi-annually.
Plan of correction
A. With respect to the specific situation cited: There were no negative outcomes identified related to the missed semi-annual review of resident emergency procedures with current staff, residents, and volunteers. Community’s Executive Director along with Area Facility’s Manager provided Inservice for Maintenance Coordinator. B. With respect to how the facility will identify situations with the potential for the identified concerns: Community will continue conducting monthly drills with staff and residents. Executive Director or designee will confirm orientation and semi-annual reviews of the emergency preparedness and response plan are performed are documented accordingly. C. With respect to what systemic measures have been put into place to address the citation: Executive Director or designee will confirm drills, orientation, and semi-annual review of emergency preparedness and response plan performed in the community and have been acknowledged by staff, residents, and volunteers and documented appropriately. Issues identified will be resolved and brought to QAPI. D. With respect to how the plan of correction will be monitored: Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and for addressing and resolving variances that may occur.
22VAC40-73-240-F
Based on volunteer record review and staff interview, the facility failed to ensure that prior to beginning volunteer service, all volunteers should attend an orientation including information on their duties and responsibilities, resident rights, emergency procedures, and infection control. Volunteers should sign and date a statement that they have received and understand this information.
Evidence
  1. Volunteer 5’s (start date, 10/01/2025) record did not include orientation that included duties and responsibilities, resident rights, emergency procedures, and infection control.
  2. Volunteer 6’s (start date, 04/18/2025) record did not include orientation that included emergency procedures and infection control.
  3. During the onsite inspection, 03/10/2026, staff 7 acknowledged that prior to beginning volunteer services, volunteer 5 did not receive an orientation that included duties and responsibilities, resident rights, emergency procedures, and infection control; and volunteer 6 did not receive an orientation that included emergency procedures and infection control.
Plan of correction
A. With respect to the specific situation cited: There were no negative outcomes resulting from volunteers missing orientation. Current volunteers have received orientation on their duties and responsibilities. Executive Director provided Inservice to Activity & Volunteer Coordinator B. With respect to how the facility will identify situations with the potential for the identified concerns: Executive Director conducted an orientation to current volunteers. Executive Director reeducated Activities and Volunteer Coordinator on the proper process to follow with new volunteers prior to starting volunteer services including duties and responsibilities, resident rights, emergency procedures, and infection control prior to volunteer start date. C. With respect to what systemic measures have been put into place to address the citation: The Executive Director or designee will confirm new volunteers receive community orientation that include duties and responsibilities, resident rights, emergency procedures, and infection control prior to start date. Executive Director or designee will confirm required orientation has been completed for current volunteers and incoming volunteers. Issues identified will be resolved and brought to QAPI. D. With respect to how the plan of correction will be monitored: Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and for addressing and resolving variances that may occur.
22VAC40-73-930-D
Based on resident record review and staff interview, the facility failed to ensure that once the resident had gone to bed each evening until the resident had arisen each morning, at minimum, direct care staff should make rounds no less often than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility. Any agreement for a different frequency must be in writing, specify the frequency, be signed and dated by the resident and the facility, and be retained in the resident’s record. If there is a change in the resident’s condition or care needs, the agreement should be reviewed and if necessary, the frequency of rounds should be adjusted. If an adjustment was made, the former agreement should be replaced with a new agreement or with compliance with the frequency specified in this subdivision.
Evidence
  1. Resident 1’s individualized service plan (ISP; effective date, 03/05/2026) stated, “I am unable to use my signaling device due to my diagnosis of dementia and require safety needs to be anticipated and met.”
  2. During the onsite inspection, 03/10/2026, licensing inspector (LI) reviewed the last 30 days of the Nightly Safety Check documentation, which indicated that rounds were only documented as completed for 6 days, 03/05-10/2026.
  3. Resident 1’s nightly safety checks were completed twice on 03/05/2026; three times on 03/08/2026; four times on 03/07/2026 and 03/10/2026.
  4. Resident 2’s ISP (effective date, 12/03/2025) stated, “I am unable to use my signaling device due to my dementia diagnosis and require safety needs to be anticipated and met.”
  5. During the onsite inspection, 03/10/2026, LI reviewed the last 30 days of the Night Safety Check documentation, which indicated that nightly rounds were not completed frequently, every two hours.
  6. Resident 2’s nighty safety checks were not completed on 02/10/2026, 02/17/2026, 02/22/2026, 02/24/2026 and 02/28/2026; once on 02/09/2026, 02/11/2026, 02/13-16/2026, 02/18/2026, 02/20-21/2026, 02/23/2026, 02/25-26/2026, 02/27/2026, 03/02/2026, and 03/06-09/2026; and twice on 02/12/2026.
  7. During the onsite inspection, 03/10/2026, staff 7 acknowledged that resident 1 and resident 2’s nightly safety checks were not documented as completed no less than every two hours.
Plan of correction
A. With respect to the specific situation cited: There were no negative outcomes resulting from not documenting rounds every two hours. Assisted Living Coordinator and Reminiscence Coordinator conducted an audit of current resident ISPs to confirm that the documentation reflects the frequency in which safety checks are conducted for residents who are unable to use signaling devices. B. With respect to how the facility will identify situations with the potential for the identified concerns: Upon admission, change of condition, and annually, the Resident Care Director and Assisted Living Coordinator and/or Reminiscence Coordinator will review the resident needs and develop an ISP based on the assessment. The Assisted Living Coordinator and/or Reminiscence Coordinator will review the ISP with the interdisciplinary team, including the resident and responsible party to verify that is it consistent with resident needs and services provided. During the time, ISPs are reviewed for accuracy and inclusion of the frequency of safety checks for residents unable to use their signaling device. C. With respect to what systemic measures have been put into place to address the citation: Resident Care Director or designee will conduct audits of the ISPs monthly for 3 months to confirm that residents unable to use their signaling device reflect the frequency in which safety checks will be conducted. Resident Care Director will present audit results to the QAPI committee monthly for 3 months. At the conclusion of the 3 months, QAPI committee will evaluate and determine if additional focus is warranted. Resident Care Director, Assisted Living Coordinator and/or Reminiscence Coordinator, or designee will provide Inservice to direct care staff regarding ISP review and required documentation standard. D. With respect to how the plan of correction will be monitored: Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and for addressing and resolving variances that may occur.
22VAC40-73-560-H
Based on resident record review and staff interview, the facility failed to ensure that the complete resident record should be retained for at least two years after the resident leaves the facility.
Evidence
  1. During the onsite inspection, 03/10/2026, licensing inspector (LI) was unable to review documentation for any fall event that occurred prior to 02/09/2026 for resident 1 and resident 2.
  2. During the onsite inspection, 03/10/2026, LI requested staff 7 to provide the documentation; however, staff 7 acknowledged an inability to provide documentation for any date that was prior to the last 30 days.
Plan of correction
A. With respect to the specific situation cited: Executive Director confirmed the community has access to resident records for at least 2 years after residents leave the community. There were no negative outcomes. B. With respect to how the facility will identify situations with the potential for the identified concerns: Executive Director or designee confirmed current resident records are available and accessible for at least 2 years by conducting routine audits C. With respect to what systemic measures have been put into place to address the citation: Executive Director re-educated Clinical and Administrative team on the importance of accessing resident records after discharge. D. With respect to how the plan of correction will be monitored: Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and for addressing and resolving variances that may occur.
22VAC40-73-990-B
Based on record review and staff interview, the facility failed to ensure the procedures in the plan for resident emergencies required in subsection A of this section should be reviewed by the facility at least every six months with all staff. Documentation of the review should be signed and dated by each staff person.
Evidence
  1. Upon request, the facility did not provide documentation that the procedures in the plan for resident emergencies were reviewed every six months with all staff.
  2. During the onsite inspection, 03/10/2026, staff 7 confirmed that the procedures in the plan for resident emergencies were not reviewed every six months with all staff.
Plan of correction
A. With respect to the specific situation cited: There were no negative outcomes identified related to the missed semi-annual review of resident emergency procedures with current staff. The Executive Director, in collaboration with the Area Facility Manager, provided an inservice training to the Maintenance Coordinator to review and reinforce the community’s emergency response procedures. B. With respect to how the facility will identify situations with the potential for the identified concerns: Executive Director or designee will confirm the procedure in the plan for resident emergencies are reviewed by the community with current staff semi-annually. C. With respect to what systemic measures have been put into place to address the citation: Executive Director or designee will confirm the procedures in the plan for resident emergencies are reviewed by the community semi-annually and acknowledged by current staff. Issues identified will be resolved and brought to QAPI. D. With respect to how the plan of correction will be monitored: Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and for addressing and resolving variances that may occur.
22VAC40-73-640-A
Based on resident record review and staff interview, the facility failed to ensure methods for verifying that medication orders were accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order.
Evidence
  1. Resident 6 was prescribed Hydromorphone 4 mg (take 1 tablet by mouth every six hours as needed for pain) on 09/02/2025. Resident 6’s September MAR indicated that Hydromorphone was transcribed and documented as administered on 09/05/2025.
  2. Resident 6 was prescribed Losartan 100 MG (take 1 tablet my mouth once daily) and RisaQuad (take 1 capsule by mouth once daily) on 09/02/2026. Resident 6’s September MAR indicated that Losartan 100 MG and RisaQuad were transcribed onto the MAR and documented as administered on 09/06/2025.
  3. During the onsite inspection, 03/10/2026, staff 7 acknowledged that resident 6’s prescribed medications (Hydromorphone 4 MG, Losartan 100 MG, and RisaQuad) were not transcribed to September 2025’s MAR within 24 hours of receipt of the new orders.
Plan of correction
A. With respect to the specific situation cited: There were no negative outcomes resulting from the not transcribing medication orders to MARs within 24 hrs. The Resident Care Director and clinical team conducted an audit of current resident medication orders and medication carts to verify that medications were accurate, current, and appropriately correlated with physician orders. B. With respect to how the facility will identify situations with the potential for the identified concerns: Wellness Nurses and Medication Care Managers were re-educated by the Resident Care Director on communication practices related to updated medication orders, EMAR medication order entry, and required documentation standards. C. With respect to what systemic measures have been put into place to address the citation: Resident Care Director or Wellness designee will conduct weekly audits for 4 weeks, monthly audits for 2 months, to confirm accuracy between physician orders and the EMAR. During monthly audits, medication orders will be reviewed to determine if medications are still relevant. Issues that may be identified will be addressed and resolved and refresher training initiated as needed. Results of audit will be presented by Resident Care Director or wellness designee at QAPI for 3 months. QAPI Committee will evaluate the results of medication order audits. D. With respect to how the plan of correction will be monitored: Executive Director or designee will monitor for ongoing compliance routinely – addressing, documenting, and resolving variances that may occur.
22VAC40-73-460-D
Based on resident record review and staff interview, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls.
Evidence
  1. Resident 1’s individualized service plan (ISP; effective date, 03/05/2026) stated, “check on me at frequent intervals EVERY 2 Hours to see if I need any assistance and to offer me reassurance.”
  2. The fall report indicated that resident 1 experienced a fall on 01/14/2026. Upon request, the facility was unable to provide documentation that staff checked on resident 1 every two hours following the fall.
  3. Resident 2’s ISP (effective date, 12/03/2025) stated, “check on me at frequent intervals (every 2 hours) to see if I need any assistance and to offer me reassurance.”
  4. The assessment report indicated that resident 2 experienced a fall on 04/11/2025, 05/31/2025, 06/27/2025, 07/01/2025, 11/03/2025, 11/12/2025, and 01/14/2025. Upon request, the facility was unable to provide documentation that staff checked on resident 2 every two hours following each fall.
  5. During the onsite inspection, 03/10/2026, staff 7 acknowledged that after experiencing a fall, staff did not provide supervision to include attention to specialize needs and prevention of falls for resident 1 and resident 2, as indicated in their ISPs.
Plan of correction
A. With respect to the specific situation cited: There were no negative outcomes resulting from not providing oversight of the resident ISPs. Current resident ISP were reviewed and updated. Assisted Living Coordinator and Reminiscence Coordinator conducted an audit of current resident ISPs. B. With respect to how the facility will identify situations with the potential for the identified concerns: Assisted Living Coordinator and/or Reminiscence Coordinator or designee provided Inservice to direct care staff regarding resident ISP review including providing supervision of resident schedules, care, activities, attention to specialized needs, including fall prevention. Assisted Living Coordinator and/or Reminiscence Coordinator will continue auditing resident ISPs to confirm accuracy. C. With respect to what systemic measures have been put into place to address the citation: Assisted Living Coordinator and/or Reminiscence Coordinator or designee will continue to audit current resident ISP to confirm proper documentation is being followed according to resident ISP. Issues identified will be corrected and brought to QAPI D. With respect to how the plan of correction will be monitored: Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and for addressing and resolving variances that may occur.
November 12, 2025Complaint survey0 violations
Inspection dates
11/12/2025
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
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: 11/12/2025 Time in: 11:24 AM Time out: 11:53 AM 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 10/30/2025 regarding allegations in the area(s) of: Buildings and Ground and Complaint Investigation 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: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector observed residents watching television and engaged in scheduled activities. LI toured areas related to the complaint investigation and did not note any abnormalities. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 19, 2025Inspection3 violations
Inspection dates
02/19/2025, 03/04/2025
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 GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
Licensing inspector (LI) reviewed standards 22VAC40-73-240 and 22VAC40-73-830.
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: 02/19/2025 Time in: 11:08 a.m. Time Out: 5:49 p.m. 03/04/2025 Time in: 10:41 a.m. Time out: 1:49 p.m. 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: 74 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 6 Observations by licensing inspector: Licensing inspector (LI) observed the physical plant of the facility. LI observed residents dining for breakfast and lunch and participating in scheduled activities. LI observed a medication pass. 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. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
22VAC40-73-50-A
Based upon record review and staff interview, the facility failed to prepare a statement on a form developed by the department of Social Services.
Evidence
  1. The Assisted Living Facility Disclosure Statement was prepared on a previous Department of Social Services form. The form was updated by the department on 01/23/2025.
  2. On 02/19/2025, LI interviewed staff 5 who confirmed that the disclosure statement was not updated on 01/23/2025.
Plan of correction
A. With respect to the specific situation cited: Community’s Executive Director updated Disclosure Statement with current form from VDSS (updated 1/23/2025). B. With respect to how the facility will identify situations with the potential for the identified concerns: Executive Director or designee will remain up to date with messaging from Virginia Department of Social Services to confirm community is utilizing current forms. C. With respect to what systemic measures have been put into place to address the citation: Executive Director or designee will confirm residents with move-in dates after 1/23/2025 receive and acknowledge updated Disclosure Statement. D. With respect to how the plan of correction will be monitored: Disclosure Statement was updated on 2/20/2025.
22VAC40-73-950-E
Based upon record review and staff interviews, the facility failed to develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers. The review was documented by signing and dating.
Evidence
  1. Upon request the facility did not provide the emergency preparedness and response plan semi-annual review with staff, residents, and volunteers.
  2. On 02/19/2025, licensing inspector (LI) interviewed staff 5 who confirmed that the semi-annual review of the emergency preparedness and response plan was not completed within the last year.
Plan of correction
A. With respect to the specific situation cited: Community’s Executive Director (ED) along with Area Facility’s Manager provided Inservice for Maintenance Coordinator. B. With respect to how the facility will identify situations with the potential for the identified concerns: Community will continue conducting monthly drills with staff and residents. Executive Director will confirm drills performed are documented. C. With respect to what systemic measures have been put into place to address the citation: Executive Director or designee will confirm drills performed in the community and have been acknowledged by staff and residents, and documented appropriately. Issues identified will be resolved and brought to QAPI. D. With respect to how the plan of correction will be monitored: Semi-annual review of emergency preparedness plan will be monitored by Executive Director or designee monthly for 3 months and ongoing semi-annually.
22VAC40-73-950-F
Based upon record review and staff interviews, the facility failed to review the emergency preparedness plan annually by signing and dating the plan.
Evidence
  1. Upon request the facility did not provide the emergency preparedness and response plan annual review.
  2. On 02/19/2025, LI interviewed staff 5 who confirmed that the emergency preparedness and response plan was not annually reviewed.
Plan of correction
A. With respect to the specific situation cited: Community’s Executive Director (ED) along with Area Facility’s Manager provided Inservice for Maintenance Coordinator. B. With respect to how the facility will identify situations with the potential for the identified concerns: Community will continue conducting monthly drills with staff and residents. Executive Director will confirm drills performed are documented. C. With respect to what systemic measures have been put into place to address the citation: Executive Director or designee will confirm drills performed in the community and have been acknowledged by staff and residents, and documented appropriately. Issues identified will be resolved and brought to QAPI. D. With respect to how the plan of correction will be monitored: Annual review of the emergency preparedness plan will be monitored by the Executive Director or designee monthly for 3 months and ongoing annually.
October 21, 2024Complaint survey1 violation
Inspection dates
10/21/2024
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: 10/21/2024 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 08/21/2024 regarding allegations in the areas of: Resident Care and Related Services and Complaint Investigation Number of residents present at the facility at the beginning of the inspection: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed residents participating in individual pursuits, such as returning from community outings, watching television, engaging with peers and staff. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-460-A
Based on record review and interview, the facility failed to assume general responsibility for the health, safety, and well-being of the residents.
Evidence
  1. Resident #1’s “Move in Record” indicated the resident’s status as a full code.
  2. Resident #1’s record indicates on 08/19/2024 the resident “was found unresponsive with no pulse or BP (blood pressure) and was pronounced deceased in her room.”
  3. During the onsite inspection on 10/21/2024, Staff #1 acknowledged Resident #1 was found unresponsive laying in their bed on 08/19/2025 and CPR was not performed.
Plan of correction
A. With respect to the specific situation cited: Community’s Executive Director (ED) conducted investigation day of event. Following investigation, ED, Resident Care Director (RCD), Assisted Living Coordinator (ALC) conducted Inservice with current team members detailing how to respond to medical emergencies. B. With respect to how the facility will identify situations with the potential for the identified concerns: The Executive Director conducted an in-service with current team members on the proper procedure to follow during a medical emergency. The community will continue to inservice current team members. New Team Members will be in-serviced during their community introduction within 30 days of hire. C. With respect to what systemic measures have been put into place to address the citation: Executive Director and/or designee will conduct training with current team members on responding to medical emergencies on an ongoing basis: When new team members are onboarded, this training will be assigned and included in their community introduction within 30 days of hire and semiannually thereafter. Executive Director or designee will continue random drills to confirm proper processes are followed during a resident emergency weekly for 4weeks. Issues identified will be resolved and brought to QAPI. D. With respect to how the plan of correction will be monitored: Inservice following reportable event was completed 8/19/2024.
August 16, 2024Complaint survey0 violations
Inspection dates
08/16/2024
Areas reviewed
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: 08/16/2024 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: 98 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: Number of interviews conducted with residents: Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings The evidence gathered during the investigation did not support the allegations 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 16, 2024Complaint survey0 violations
Inspection dates
08/16/2024
Areas reviewed
Resident Care and Related ServicesPersonnel
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: 08/16/2024 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: 98 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: Number of interviews conducted with residents: Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 14, 2024Inspection0 violations
Inspection dates
02/14/2024
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuilding and GroundsEmergency PreparednessAdditional Requirements for Facilities that Care for Adults with Cognitive ImpairmentsBackground Checks for Assisted Living FacilitiesSworn Statement
Comments
Date of Inspection: February 14, 2024 Type of Inspection: Renewal inspection Census: 74 Number of records reviewed and interviews conducted- 5 records, 6 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed residents participating in activity programs and eating lunch. This LI also observed medication administration and reviewed the following facility reports: health inspection reports, fire marshal reports, fire drills, emergency preparedness review with staff, medication review, dietary review, healthcare oversight and resident council. If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 4, 2023Inspection0 violations
Inspection dates
12/04/2023
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuilding and GroundsEmergency PreparednessAdditional Requirements for Facilities that Care for Adults with Cognitive ImpairmentsBackground Checks for Assisted Living FacilitiesSworn Statement
Comments
Date of Inspection: December 4, 2023 Type of Inspection: Monitoring Inspection Census 71 Number of records reviewed and interviews conducted- 6 records, 4 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed residents eating lunch and participating in activity programs. If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 11, 2023Inspection0 violations
Inspection dates
09/11/2023
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuilding and GroundsEmergency PreparednessAdditional Requirements for Facilities that Care for Adults with Cognitive ImpairmentsBackground Checks for Assisted Living FacilitiesSworn Statement
Comments
The licensing Inspector conducted an unannounced initial inspection on 9/11/23. Census 68 Number of records reviewed and interviews conducted- 4 records, 2 interviews. The Licensing Inspector observed residents eating lunch and pursuing independent activities. If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.