1 Inspection Summary
Inspection Reports Summary
Covers 20 inspections · Feb 2021 – Feb 2026Visit Reason
This report covers 20 inspections of Spring Hills Mt. Vernon (Fairfax Co) by VDSS from February 26, 2021 to February 2, 2026, including complaint and routine inspections.
Complaint Details
Twelve inspections were complaint surveys prompted by allegations in areas such as Admission, Retention and Discharge of Residents, Resident Care and Related Services, Administration and Administrative Services, Buildings and Grounds, Emergency Preparedness, and Complaint Investigation. Some complaints were substantiated with violations issued; others were not supported by evidence.
Findings
Across that history VDSS cited 54 violations under 46 distinct standards. 16 of 20 visits ended with violations and 12 were complaint prompted.
Violations (52)
22VAC40-73-950-F: Facility failed to review emergency preparedness plan annually or as needed with documentation.
22VAC40-73-650-E: Resident record lacked physician's signed or dated order for medications.
22VAC40-73-290-A: Written work schedule missing job classifications and in-charge indication.
22VAC40-73-280-A: Staffing inadequate in knowledge, skills, and numbers per resident needs.
22VAC40-73-680-M: PRN medications not available, properly labeled, or stored for resident.
22VAC40-73-950-E: Failed to implement semi-annual review of emergency preparedness plan with documentation.
22VAC40-73-970-A: Fire drills not conducted quarterly on each shift with proper frequency and participation.
22VAC40-73-680-B: Medications not administered by licensed or provisional medication aide as required.
22VAC40-73-280-B: No written plan specifying number and type of direct care staff related to resident acuity.
22VAC40-73-640-A: Medication management plan incomplete; orders not transcribed timely; improper disposal.
22VAC40-73-650-C: Physician's oral orders not reviewed and signed within 14 days.
22VAC40-73-50-A: Disclosure statement not provided on form developed by the department.
22VAC40-73-830-E: Failed to provide written response to resident council recommendations prior to next meeting.
22VAC40-73-980-H: Emergency food and drinking water supply expired and not maintained as required.
22VAC40-73-220-A: Private duty personnel records lacked written information on type and frequency of services.
22VAC40-73-325-B: Fall risk rating not reviewed and updated after resident falls.
22VAC40-73-450-F: Individualized service plans not reviewed and updated yearly or as needed after changes.
22VAC40-73-680-D: Medication not administered per physician's or prescriber's instructions.
22VAC40-73-650-C: Physician's oral orders not reviewed and signed within 14 days.
22VAC40-73-70-A: Failed to report major incident to regional licensing office within 24 hours.
22VAC40-73-640-A: Medication management plan incomplete; orders not transcribed timely.
22VAC40-73-680-C: Medications administered outside one hour before or after scheduled dosing time.
22VAC40-73-880-C: Facility failed to provide air conditioning in resident areas; temperatures exceeded 80 F.
22VAC40-73-130-A: Staff failed to report suspected abuse, neglect, or exploitation of residents.
22VAC40-73-240-F: Volunteers did not attend orientation including duties, rights, confidentiality, and reporting.
22VAC40-73-50-A: Disclosure statement not provided on form developed by the department.
22VAC40-73-430-H-1: Discharge statement not signed by licensee or administrator.
22VAC40-73-390-A: Resident agreement not signed by licensee or administrator.
22VAC40-73-1110-B: Failed to perform 6-month and annual review of appropriateness for special care unit placement.
22VAC40-73-460-D: Failed to provide supervision including fall prevention as per resident schedules and care plans.
22VAC40-73-880-B: Facility used portable heating unit not approved by state fire authorities.
22VAC40-73-490-A-2: Failed to have documentation of healthcare oversight every three months as required.
22VAC40-73-860-I: Cleaning supplies not stored in locked area as required.
22VAC40-73-870-A: Interior and exterior of building not in good repair; broken windows, fencing, and doors.
22VAC40-73-310-H: Facility admitted or retained individual requiring continuous licensed nursing care.
22VAC40-73-460-D: Failed to provide supervision including fall and wandering prevention for resident.
22VAC40-73-325-C: Failed to document analysis of falls and interventions to prevent subsequent falls.
22VAC40-73-470-F: Failed to secure immediate medical attention after serious resident injury or accident.
22VAC40-73-480-E: Physician orders, services, and evaluations not recorded in resident's rehabilitative record.
22VAC40-73-450-C: Comprehensive individualized service plan not completed within 30 days after admission.
22VAC40-73-450-D: Hospice services not included on individualized service plan.
22VAC40-73-560-E: Resident records not kept current; delayed documentation of injury without reporter noted.
22VAC40-73-70-A: Failed to report major incident to regional licensing office within 24 hours.
22VAC40-73-130-A: Staff failed to report suspected abuse, neglect, or exploitation to Adult Protective Services.
22VAC40-73-680-D: Medication not administered per physician's instructions; missing doses documented.
22VAC40-73-740-A: Residents not permitted to keep reasonable personal property to maintain dignity.
22VAC40-73-740-D: Facility failed to develop and implement policy for missing resident possessions.
22VAC40-90-30-B: Sworn statement or affirmation not completed for all employment applicants.
22VAC40-90-40-B: Criminal history record report not obtained within 30 days of employment for staff.
22VAC40-73-1090-A: Resident admitted to safe, secure environment without prior licensed assessment.
22VAC40-73-1110-A: Failed to determine appropriateness of placement in special care unit prior to admission.
22VAC40-73-250-A: Staff record not maintained for at least two years after employment termination.
Report Facts
Violations cited: 54
Distinct standards: 46
Inspections on page: 20
Inspections with violations: 16
Complaint visits: 12
Employees mentioned
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