1 Inspection Summary
Inspection Reports Summary
Covers 31 inspections · Feb 2021 – Apr 2026Visit Reason
The report covers 31 inspections of The Providence Fairfax from February 9, 2021 to April 22, 2026, including complaint and routine inspections.
Complaint Details
There were 10 complaint visits. Complaints involved resident accommodations, staffing and supervision, resident care, and related services. Investigations supported some allegations and violations were issued. Some complaints involved failure to report incidents timely and failure to provide required care and supervision.
Findings
Across that history VDSS cited 66 violations under 44 distinct standards. 20 of 31 visits ended with violations cited and 11 with none. 10 inspections were prompted by a complaint.
Violations (65)
22VAC40-73-680-C: Medication administered not within one hour before or after scheduled dosing.
22VAC40-73-70-A: Major incident not reported to licensing office within 24 hours.
22VAC40-73-680-D: Medication not administered per physician or prescriber’s instructions.
22VAC40-73-680-C: Medication administered not within one hour before or after scheduled dosing.
22VAC40-73-650-B: Physician orders missing required elements including diagnosis or indications.
22VAC40-73-650-A: Medication started without valid physician or prescriber order.
22VAC40-73-210-C: Training for first year staff not started within 60 days of employment.
22VAC40-73-460-A: Failed to assume responsibility for general health, safety, and well-being of residents.
22VAC40-73-450-F: ISP not reviewed and updated at least annually and as needed for significant change.
22VAC40-73-680-I: MAR missing all 13 required components.
22VAC40-73-1080-A: Resident admitted to safe, secure unit without documented serious cognitive impairment.
22VAC40-73-1150-A: Doors to unprotected areas not monitored or secured per building and fire codes.
22VAC40-73-930-D: Staff failed to make rounds at least every two hours after resident bedtime.
22VAC40-73-650-C: Physician or prescriber’s orders not reviewed and signed within 14 days.
22VAC40-73-640-A: Medication management plan not implemented.
22VAC40-73-70-A: Major incident not reported to licensing office within 24 hours.
22VAC40-73-680-D: Medication administered not per physician or prescriber’s orders.
22VAC40-73-680-C: Medication administered not within one hour before or after scheduled dosing.
22VAC40-73-860-I: Cleaning supplies not stored in locked area.
22VAC40-73-210-B: Direct care staff did not attend at least 18 hours of annual training.
22VAC40-73-1140-B: Direct care staff did not attend at least 10 hours of cognitive impairment training within 4 months of employment.
22VAC40-73-450-F: ISP not updated as needed for significant change in resident condition.
22VAC40-73-460-H: Personal care and assistance not provided as necessary to meet resident needs.
22VAC40-73-660-B: Medication stored in resident room not secured and UAI not updated for self-administration.
22VAC40-73-470-A: Failed to meet health care service needs of residents.
22VAC40-73-260-A: Direct care staff lacked current first aid certification from approved organizations.
22VAC40-73-280-B: Failed to maintain written staffing plan specifying number and type of direct care staff.
22VAC40-73-460-B: Failed to ensure prompt response to resident needs.
22VAC40-90-40-C: Operable window not effectively screened.
22VAC40-73-450-H: Care and services specified in ISP not provided to resident.
22VAC40-73-450-F: ISP not reviewed and updated as needed for significant change.
22VAC40-73-680-B: Medication not administered according to physician orders.
22VAC40-73-680-M: PRN medication not available for resident.
22VAC40-73-610-B: Menu substitutions or additions not recorded on posted menu.
22VAC40-73-680-D: Medication not administered according to physician order.
22VAC40-73-1140-B: Direct care staff in special care unit did not attend 10 hours cognitive impairment training within 4 months.
22VAC40-73-930-D: Call bell inability not documented in ISP and rounds approval missing.
22VAC40-73-70-A: Failed to report major incident to licensing office within 24 hours.
22VAC40-73-550-G: Residents’ rights and responsibilities not reviewed annually with residents or representatives.
22VAC40-73-560-E: Resident records not kept in locked area.
22VAC40-73-970-A: Fire and emergency evacuation drills not conducted as required.
22VAC40-73-680-B: Medications not kept in pharmacy issued container until administration.
22VAC40-73-620-B: Special diet oversight not certified with required documentation.
22VAC40-73-280-B: Failed to maintain written staffing plan specifying number and type of direct care staff.
22VAC40-73-460-A: Failed to assume general health, safety, and well-being of resident.
22VAC40-73-1140-B: Direct care staff failed to attend 10 hours cognitive impairment training within 4 months.
22VAC40-73-70-A: Failed to report major incident to licensing office within 24 hours.
22VAC40-73-460-B: Failed to ensure prompt response to resident needs.
22VAC40-73-280-B: Failed to maintain written staffing plan specifying number and type of direct care staff.
22VAC40-73-460-B: Failed to ensure prompt response to resident needs.
22VAC40-73-610-B: Menu substitutions or additions not recorded on posted menu.
22VAC40-73-680-D: Medication not administered according to physician order.
22VAC40-73-680-M: PRN medication not available for resident.
22VAC40-90-50-A: Substitute staff records missing agency letter verifying criminal history checks.
22VAC40-73-120-B: Substitute staff records missing documentation of facility orientation.
22VAC40-73-50-A: Facility failed to use department disclosure form.
22VAC40-73-450-F: ISP not reviewed and updated at least annually.
22VAC40-73-450-E: ISP not signed and dated by resident or legal representative.
22VAC40-73-280-B: Failed to maintain written staffing plan specifying number and type of direct care staff.
22VAC40-73-440-A: Uniform Assessment Instrument not completed annually.
22VAC40-73-220-A: Failed to obtain written info on private duty services and provide orientation to private duty personnel.
22VAC40-73-460-B: Failed to ensure prompt response to resident needs.
22VAC40-73-70-A: Failed to report major incident to licensing office within 24 hours.
22VAC40-73-1110-B: Failed to perform six-month and annual review of appropriateness of residence in special care unit.
22VAC40-73-460-A: Failed to ensure health, safety, and well-being of residents.
Report Facts
Violations cited: 66
Distinct standards: 44
Inspections on page: 31
Inspections with violations: 20
Complaint visits: 10
Employees mentioned
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