Virginia DSS · Assisted Living Facility

Arden Courts (Fair Oaks)

📍 12469 Lee Jackson Memorial Hwy, Fairfax, VA, 22033

ID 52462One Year licenseActive
6
Inspections
On record
4
With violations
Visits that cited something
2
Clean visits
Nothing cited
18
Violations cited
Individual findings
16
Standards cited
Distinct rules
0
Complaint visits
Prompted by a complaint

Arden Courts (Fair Oaks) was inspected 6 times between August 14, 2025 and April 22, 2026 by the Virginia Department of Social Services. 4 of those visits ended with violations cited and 2 with none. Across that history VDSS cited 18 violations under 16 distinct standards.

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
03/24/2027
Administrator
Joel Bednoski
Licensing inspector
Jacquelyn Kabiri
Inspector phone
(703) 397-3017
Approved for
Non-Ambulatory · Special Care Unit · Assisted Living

Inspection History

6

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

April 22, 2026Inspection5 violations
Inspection dates
04/22/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 04/22/2026, 10:15 a.m. to 1:00 p.m. 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 04/08/2026 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: 44 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: 2 Observations by licensing inspector: Facility completed recent redecorating/upgrades. Additional Comments/Discussion: None. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); areas of non-compliance with standard(s) or law were: 70.A, 450.C2, 440, 73.40, 430.H.2. Resident Care and Related Services A violation notice was issued; any violation(s) not related to the (complaint(s)/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. 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on record review and staff interviews, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of the resident.
Evidence
  1. Upon admission on 02/19/2026, there was no documentation in the facility’s progress notes of resident 1 or the resident 1’s physical examination on 02/18/2026 indicating the presence of an unstageable ulcer on the left heel.
  2. On 04/01/2026, staff 4 wrote in facility progress notes, “resident noted with a wound on his left heel. MD in house and assesses the resident with new order given for home health wound nurse consult”.
  3. On 04/03/2026, staff 3 wrote progress notes indicating that a wound nurse evaluated and treated an unstageable ulcer on the left heel measuring 1.0 cm x 1.8 cm x 0.1 cm on resident 1.
  4. The Licensing Inspector did not receive any prior reports indicating that resident 1 had developed an unstageable foot ulcer that was not documented as healing.
  5. During the onsite inspection on 04/22/2026, staff 1 and staff 2 confirmed that no incident report had been submitted to the DSS Licensing Division regarding the development of an unstageable wound that was not documented as healing for resident 1.
Plan of correction
1. Facility will report any major incidents to the regional licensing office within 24 hours of the incident. These will be submitted via email to our licensing inspector with additional seven day follow-up. Designated Party Responsible Resident Services Coordinator, Executive Director Audit Plan 1.Incidents will be documented by the shift supervisor, reviewed daily by the Residents Services Coordinator and the Executive Director. 2. A comprehensive review of all current residents’ conditions and incident reports over the past 30 days will be reviewed. 1. Immediate (effective 5/8/2026) 2. Review to be completed by 5/22/2026
22VAC40-73-430-H-2
Based on the record review and interview, the facility failed to ensure that at the time of discharge, a copy of the written discharge statement was retained in the resident's record.
Evidence
  1. During the onsite inspection on 04/22/2026, a review of resident 1’s record indicated, through progress notes, that the resident was discharged from the facility on 04/06/2026. A written discharge statement or any discharge documentation was not noted in the resident 1’s record.
  2. During an interview, staff 1 and staff 2 confirmed that resident 1 was discharged on 04/06/2026; however, they were unable to provide the discharge paperwork during the inspection.
Plan of correction
Facility will complete a discharge statement for all discharged residents. Facility will utilize Discharge Notification and Statement Form from VA DSS website. Resident Services Coordinator, Executive Director1.All future residents who are discharged from the facility will have a discharge form completed and placed in resident file prior to closing out resident file. 2.We will complete and audit of all residents discharged in the last 90 days, and will audit all charts every 30 days going forward. 1.Immediate (5/8/2026) 2.5/22/2026
22VAC40-73-450-E
Based on the record review and staff interview, the facility failed to ensure that an Individualized Service Plan (ISP) is signed and dated by the licensee, administrator, or their designee, and by the resident or their legal representative.
Evidence
  1. During the onsite inspection on 04/22/2026, the ISP dated 04/01/2026 for resident 1 (admitted on 02/19/2026) was not signed by the licensee, administrator, or their designee, and by the resident or their legal representative.
  2. Staff 1 acknowledged that the ISP for resident 1 was not signed.
Plan of correction
Facility will ensure all ISP’s are signed and dated by the facility administrator. Facility will attempt to obtain responsible party signatures for all care plans, and will document accordingly if unable to obtain. Resident Services Coordinator, Executive Director All ISP’s will be reviewed at time of reassessment by the facility administrator prior to completion for accuracy. Resident Services Coordinator will contact responsible party and document in progress notes attempts made with regards to ISP review. 5/22/2026
22VAC40-73-440-B
Based on the record review and staff interview, the facility failed to ensure that the Universal assessment instrument (UAI), was completed by a qualified assessor who has successfully completed state approved training on the uniform assessment instrument and level of care criteria for either public or private pay assessments, provided the administrator or the administrator’s designated representative has successfully completed such training and approves and then signs the completed UAI, and the facility maintains documentation of completed training.
Evidence
  1. Resident 1’s most current UAI, dated 03/14/2026, was not signed by the Administrator.
  2. Staff 2 confirmed that the UAI was not signed by the Administrator.
Plan of correction
Facility will have all UAI’s completed by qualified assessor, and signed by the facility executive director. Resident Services Coordinator, Executive Director UAI’s will be revied at each resident assessment (for admission) and reassessment (current residents). Facility will complete an audit of all current UAI’s to ensure compliance. 5/22/2026
22VAC40-73-450-C
Based on the record review and staff interview, the facility failed to ensure that an Individualized Service Plan (ISP) have a written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them.
Evidence
  1. The Individualized Service Plan (ISP) dated 04/02/2026 for resident 1, admitted on 02/19/2026, did not include specific details regarding wound care services to include who was responsible for providing care, the frequency of services, or the type of care to be provided.
  2. A review of physician’s orders indicated that resident 1 received the following services: a. On 03/25/2026, home health physical therapy (PT) and occupational therapy (OT) services were initiated. b. On 04/01/2026, a wound care consult was ordered for the resident’s heel and elbows. c. On 04/03/2026, Collateral contact 1 was ordered to provide care for skin tears on the elbows. d. On 04/03/2026, Collateral contact 1 was ordered to clean an unstageable ulcer on the left heel. e. On 04/06/2026, a home health wound nurse conducted a consult and provided treatment for the left heel wound.
  3. During an interview on 04/22/2026, staff 1 and staff 2 confirmed that the above wound care service details were not included in the ISP of resident 1.
Plan of correction
Facility will update all ISP’s with identified needs and plan of care to address them with goals, actions, staff designation/third party provider, and timeline. Additionally, facility will obtain progress notes for any visiting third party provider providing care/services to the resident for the identified condition. Resident Services Coordinator. Residents who have been identified as needing additional services will be documents on the 24 hour report until issue has been resolved.5/22/2026
February 18, 2026Inspection4 violations
Inspection dates
02/18/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 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 IMPAIRMENTS63.2- (18) Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation
Technical assistance
TA: Common restrooms need toilet tissue and paper towels.
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: 02/18/2026, 10:00 a.m. to 2:45 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: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Activities and lunch Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-325-A
Based on record review, the facility failed to ensure that a written fall risk rating was completed for residents who met the criteria for assisted living care by the time the comprehensive Individualized Service Plan (ISP) was completed.
Evidence
  1. Comprehensive Individualized Service Plan for resident 1 (admitted 02/13/2026) who met the criteria for assisted living care, was completed on 02/18/2026, with no fall risk rating.
  2. Resident 3, admitted 09/25/2025, who met the criteria for assisted living care, does not have a written fall risk rating or assessment in their record.
  3. Staff 1 was unable to provide the requested documents at the time of inspection.
Plan of correction
Corrective Action: Resident records were reviewed and fall risk assessments were completed and added to the resident record as required. Systemic Prevention Measures: The Resident Services Coordinator will ensure fall risk assessments are completed as part of the comprehensive service plan process and documented in the resident record. Staff responsible for assessments were re-educated on documentation requirements. Responsible Person: The Executive Director or designee will validate compliance through weekly checks for 4 weeks and monthly audits for 2 months
22VAC40-73-720-A
Based on the review of facility records and staff interview, the facility failed to ensure that Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest were valid and issued by the resident’s attending physician.
Evidence
  1. Resident 1, admitted on 02/13/2026, had a DNR form in their record; however, it was not signed by a physician.
  2. Resident 2, admitted on 02/14/2026, had a DNR form in their record; however, it was not signed by a physician.
  3. Staff 1 acknowledged the LI’s findings.
Plan of correction
Corrective Action: Resident records were reviewed to verify DNR orders are properly completed and signed by the attending physician. Any incomplete documentation was addressed and corrected with the appropriate physician. Systemic Prevention Measures: The Resident Services Coordinator will verify that all DNR documentation is complete, signed by the attending physician, and maintained in the resident record prior to implementation. A chart review checklist will be used to ensure compliance. Responsible Person: The Executive Director or designee will validate compliance through weekly checks for 4 weeks and monthly audits for 2 months.
22VAC40-73-450-A
Based on record review and interview, the facility failed to ensure that on or within seven days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects their health, safety, and welfare.
Evidence
  1. Resident 2, admitted 02/14/2026, does not have an individualized service plan present in their record.
  2. Staff 1 confirmed LI’s findings.
Plan of correction
Corrective Action: Resident records were reviewed to ensure a preliminary plan of care or individualized service plan is present and completed within required timeframes. Systemic Prevention Measures: The Resident Services Coordinator will ensure preliminary plans of care are developed on or within seven days prior to admission and tracked using an admission documentation checklist to ensure compliance with regulatory requirements. Responsible Person: The Executive Director or designee will validate compliance through review of all new resident admissions weekly for 4 weeks and monthly audits for 2 months to ensure preliminary plans of care are completed within the required timeframe. 03/06/26
22VAC40-73-120-A
Based on record review and staff interview, the facility failed to ensure that orientation and training required in subsections B and C of this section shall occur within the first seven working days of employment. Until this orientation and training is completed; the staff person may only assume job responsibilities if under the sight supervision of a trained direct care staff person or administrator.
Evidence
  1. Staff 2’s record (hire date: 09/25/2025) did not include documentation confirming the completion of orientation or initial training.
  2. During the onsite inspection on 02/18/2026, staff 1 acknowledged the LI’s findings.
Plan of correction
Corrective Action: Employee records were reviewed to verify documentation of orientation and required initial training. Missing documentation was obtained and placed in the appropriate personnel files. Systemic Prevention Measures: The Executive Director or designee will ensure that all new employees complete required orientation and initial training within the first seven working days of employment. A personnel file checklist will be used to confirm that all required documentation is completed and maintained in the employee file. Responsible Person: The Executive Director or designee will validate compliance through weekly checks for 4 weeks and monthly audits for 2 months 03/06/26
January 22, 2026Inspection6 violations
Inspection dates
01/22/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 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: 01/22/2026, 10:40 a.m. to 1:30 p.m. 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 01/07/2026 regarding allegations in the area(s) of: Resident Care and Related Services, Building and Grounds. Number of residents present at the facility at the beginning of the inspection: 45 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Lunch and activities in the activity room Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services and Building and Grounds A violation notice was issued; any violation(s) not related to the complaint(s) 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. 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-530-C
Based on direct observation and staff interview, the facility failed to ensure residents had freedom of movement between common areas and their personal spaces.
Evidence
  1. During a tour of the memory care facility, the Licensing Inspector (LI) observed three locked resident rooms on the Bayridge hallway while the residents were outside of their rooms. The LI also observed one locked resident room on the Harvest Glen hallway.
  2. In an interview with the LI, staff 1 confirmed awareness of the three locked resident room doors on the Bayridge hallway. Staff 1 confirmed the LI’s findings.
  3. Photo evidence was obtained.
Plan of correction
Corrective Action: Resident room doors were reviewed to ensure they remain accessible and are not secured in a manner that restricts resident access. Rooms were left unsecured to support resident freedom of movement. Door hardware that allows rooms to remain locked is being replaced with compliant passage/privacy knobs to ensure rooms remain accessible while maintaining resident privacy. Systemic Prevention Measures: Staff were re-educated that resident room doors must remain accessible and may not be secured in a manner that restricts resident access. Shift rounds will include verification that resident rooms remain accessible. Maintenance will replace non-compliant door hardware to ensure consistency throughout the community. Responsible Person: The Executive Director or designee will conduct daily rounds for 2 weeks and weekly rounds for 2 months to ensure compliance and verify completion of hardware updates
22VAC40-73-440-F
Based on resident record review and staff interview, the facility failed to ensure the Uniform Assessment Instrument (UAI) was completed within 90 days prior to admission to the assisted living facility.
Evidence
  1. On 01/22/2026, during the inspection, the Licensing Inspector (LI) reviewed resident 1’s record (admission date: 07/21/2025) and was unable to locate a UAI assessment form.
  2. During the interview on 01/22/2026, staff 1 was unable to locate or produce a UAI for resident 1 prior to the conclusion of the inspection.
Plan of correction
Corrective Action: A review of current resident records was conducted to verify that required Uniform Assessment Instruments are present and current. Systemic Prevention Measures: An admission compliance checklist has been implemented to ensure a current UAI is obtained and filed prior to admission. The Resident Services Coordinator will verify completion prior to move-in. Responsible Person: The Executive Director or designee will validate compliance through review of all new admissions weekly for 4 weeks and monthly audits for 2 months
22VAC40-73-925-B
Based on observations, the facility failed to ensure that common face/hand washing sinks have paper towels or an air dryer.
Evidence
  1. The Bayridge common unisex bathroom, located near the TV room, was observed to lack paper towels or an air dryer.
  2. The Cloverdale common unisex bathroom was observed to lack paper towels or an air dryer.
  3. Photo evidence was obtained.
Plan of correction
Corrective Action: All handwashing areas were inspected to ensure paper towels are available. Standardized paper towel dispensers have been ordered and are being installed to provide uniform equipment and proper function throughout all houses in the community. Systemic Prevention Measures: Housekeeping staff were re-educated to verify paper towel availability during cleaning rounds and to report empty or malfunctioning dispensers immediately. Maintenance will replace any damaged or inconsistent units and continue standardizing dispensers community-wide. This will remain an ongoing process to ensure consistency and readiness. Responsible Person: The Executive Director or designee will validate compliance during weekly checks for four (4) weeks and monthly audits for two (2) months to ensure sustained compliance.
22VAC40-73-450-A
Based on record review and interview with staff, the facility failed to ensure a preliminary plan of care addressed the basic needs of the resident that adequately protects his health, safety, and welfare.
Evidence
  1. The record for resident 1, admission date of 07/22/25, did not contain a preliminary plan of care completed on or within 7 days of admission or an Individualized Service Plan (ISP) completed on the day of admission.
  2. Staff 1 was unable to produce the ISP for resident 1 before the conclusion of the inspection on 01/22/2026.
Plan of correction
Corrective Action: The individual referenced in the citation is no longer residing in the community. The resident was discharged, and therefore the admission documentation deficiency no longer applies. Systemic Prevention Measures: The admission process has been reviewed with the management and nursing teams to ensure all required admission documentation is completed prior to or at the time of move-in. An admission checklist will be utilized to verify completeness and prevent future omissions. Responsible Person: The Executive Director or designee will review all new admissions weekly for four (4) weeks and monthly for two (2) months to ensure ongoing compliance.
22VAC40-73-925-A
Based on observation and staff interview, the facility failed to have an adequate supply of toilet tissue accessible at each commode.
Evidence
  1. The Bayridge common unisex bathroom, located in proximity to the TV room, had no toilet paper, and the spindle for holding the toilet paper was missing.
  2. Staff 1 acknowledged the LI’s findings.
  3. Photo evidence was obtained.
Plan of correction
Corrective Action: All bathrooms were checked and stocked to ensure toilet tissue is available at each commode. Systemic Prevention Measures: Housekeeping staff were re-educated to check and restock bathroom supplies during routine cleaning rounds and to report missing equipment immediately. Responsible Person: The Executive Director or designee will validate compliance during scheduled weekly checks for 4 weeks and monthly audits for 2 months.
22VAC40-73-870-E
Based on observation and staff interview, the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition, except that furnishings and equipment owned by a resident shall be, at a minimum, in safe condition and not soiled in a manner that presents a health hazard.
Evidence
  1. During the facility tour at 11:02 a.m. on 01/22/2026, with Staff 1 present, the Licensing Inspector (LI) made the following observations: Cloverdale Hallway: a. The community hallway toilet was unclean, with debris and waste observed on the toilet seat and in the toilet bowl. b. The ceiling above the vent in the TV community room had a large brown ring consistent with a possible water stain.
  2. Bayridge Hallway: a. Room 9 was unoccupied; however, the LI observed warped wood beneath the bathroom sink cabinet. b. The bathroom in room 9 was noted to have yellow circular staining on the flooring in the immediate area surrounding the toilet. c. The door to room 9 had cracked and deteriorating wood around the locking mechanism and doorknob.
  3. The lobby bathroom for visitors and staff use had a broken wall-mounted paper towel dispenser.
  4. Photo evidence was obtained.
Plan of correction
Corrective Action: Affected areas were cleaned and immediate sanitation concerns were addressed. Maintenance repairs have been initiated. Replacement of damaged materials, including sink cabinet components and stained ceiling tiles, is in progress to ensure all fixtures and surfaces are clean and in good repair. Systemic Prevention Measures: Housekeeping and maintenance staff were re-educated on environmental standards. Weekly environmental rounds will be conducted to identify and correct cleanliness or repair needs promptly. Responsible Person: The Executive Director or designee will validate compliance through weekly checks for 4 weeks and monthly audits for 2 months until all repairs are completed.
November 5, 2025Inspection3 violations
Inspection dates
11/05/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 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 IMPAIRMENTS22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 The License
Technical assistance
Update Disclosure statement form to current DSS 10/24.
Comments
Type of inspection: ¿Monitoring¿ Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/05/2025, 11:30 a.m. to 3:00 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: 53 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5, 2 partial reviews. Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Lunch and Activities Additional Comments/Discussion: None 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-680-M
Based on a medication cart audit, the facility failed to ensure medications were properly labeled for the specific resident.
Evidence
  1. The LI found a tube of Bacitracin Ointment in the medication cart with no label or identifiable resident information.
  2. Staff 1 observed the LI’s findings.
  3. Photo evidence obtained.
Plan of correction
Immediate Correction (Completed 11/05/2025): The unlabeled Bacitracin ointment was discarded. A full medication cart audit was completed. Systemic Prevention Measures: The Resident Service Coordinator will be re-educated on reviewing medication carts for proper labeling. Responsible Person: The Executive Director or designee will validate compliance through weekly medication cart audits for 4 weeks, then monthly audits for 2 months ensure compliance.
22VAC40-73-450-E
Based on resident record review, the facility failed to ensure the Individualized Service Plan (ISP) is signed and dated by the licensee, administrator, or their designee and by the resident or their legal representative.
Evidence
  1. Resident 5’s admission date was 01/11/2024, and their ISP was not signed or dated by a facility representative or legal representative.
  2. Staff 1 was not able to produce an updated ISP for resident 5 during the inspection.
Plan of correction
Immediate Correction: The Resident Service Coordinator will review the ISP with Resident #5’s family and obtain the appropriate signatures from all required parties. Systemic Prevention Measures: The Resident Service Coordinator will be re-educated on ensuring all ISPs are fully completed, signed, and updated as required. Responsible Person: The Executive Director or designee will validate compliance through weekly ISP audits for 4 weeks and monthly audits for 2 months
22VAC40-73-750-E
Based on direct observation and staff interview, the facility failed to ensure that there were sufficient bed and bath linens in good repair so that residents always have clean sheets, pillowcases, and blankets.
Evidence
  1. On 11/05/2025, the LI observed resident 1’s bedding inside their apartment. The LI noted a gray quilt bedspread with several circular brown spots on the outer surface. The inner lining of the quilt contained approximately 10 small brown spots.
  2. Staff 1 confirmed the LI’s findings and immediately asked the staff to take care of the linen.
  3. Photo evidence obtained.
Plan of correction
Immediate Correction: The stained bedding observed in Resident #1’s room was removed and replaced with clean linens. A full check of the resident’s bedding was completed, and any additional items needing replacement were addressed. Systemic Prevention Measures: Housekeeping staff will be re-educated on ensuring all bed and bath linens are clean, free of stains, and in good repair during daily room cleaning. Responsible Person: The Executive Director or designee will validate compliance during scheduled weekly checks for 4 weeks and monthly audits for 2 months.
November 5, 2025Inspection0 violations
Inspection dates
11/05/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: ¿Monitoring¿ Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/05/2025, 9:30 a.m. to 11:30 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 11/02/2025 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services and Building and Grounds. Number of residents present at the facility at the beginning of the inspection: 53 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: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch and Activities Additional Comments/Discussion: None. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 14, 2025Inspection0 violations
Inspection dates
08/14/2025
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS
Comments
Type of inspection: Initial Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/14/2025, 9:45 a.m. to 10:35 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: 52 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: none Additional Comments/Discussion: none An exit meeting will be conducted to review the inspection findings. 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 should the facility be issued a license to operate. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.