3 Reports · 1 Summary
Inspection Summary
20 inspections covered, Mar 2021 – Apr 2026.
Inspection Reports Summary
Visit Reason
This report covers 20 inspections of The Virginian(Fairfax Co) from March 29, 2021 to April 22, 2026, including routine, complaint, monitoring, and renewal inspections.
Complaint Details
Four inspections were prompted by complaints regarding staffing and supervision, resident care, buildings and grounds, and admission, retention, and discharge of residents. Investigations supported some allegations and violations were issued accordingly.
Findings
Across that history VDSS cited 55 violations under 43 distinct standards. Four inspections were prompted by a complaint.
Deficiencies (45)
22VAC40-73-930-B: Facility failed to ensure signaling device continuously staffed and permits origin determination.
22VAC40-73-50-A: Disclosure form information was not kept current.
22VAC40-73-280-B: Written staffing plan did not specify number and type of staff required.
22VAC40-73-550-G: Rights and responsibilities of residents not reviewed annually with each resident and staff.
22VAC40-73-320-A: Physical exam report lacked statement on capability to administer medication.
22VAC40-73-860-I: Cleaning products and hazardous items not stored in locked areas.
22VAC40-90-40-B: Criminal records not obtained prior to 30th day of employment.
22VAC40-73-650-B: Physician orders lacked route or specific indications for administering drugs.
22VAC40-73-860-D: Operable windows were not effectively screened.
22VAC40-73-680-D: Medication not administered in accordance with physician or prescriber orders.
22VAC40-73-70-C: Incident reports not submitted to licensing office within seven days.
22VAC40-73-130-A: Mandated reporters failed to report suspected abuse as required by law.
22VAC40-73-470-F: Documentation of serious accident or injury and notifications not in resident record.
22VAC40-73-40-A: Failed to ensure compliance with regulations and terms of license and facility policies.
22VAC40-73-70-A: Major incident not reported to licensing office within 24 hours.
22VAC40-73-440-A: Uniform Assessment Instrument not completed annually or with significant change.
22VAC40-73-450-F: Individualized service plan not reviewed and updated at least annually or as needed.
22VAC40-73-460-B: Care provision and service delivery not resident entered with prompt staff response.
22VAC40-73-390-C: ISP did not document inability to use signaling device or specify frequency of rounds.
22VAC40-73-120-C: Staff orientation not completed within first seven working days of employment.
22VAC40-73-720-A: Written Do Not Resuscitate order not included in individualized service plan.
22VAC40-73-350-C: Residents not annually informed about sex offender information and acknowledgement not maintained.
22VAC40-73-660-A: Medicine cabinet used for medication storage was not locked.
22VAC40-73-950-A: Documentation of initial and annual contact with local emergency coordinator missing.
22VAC40-73-100-A: Annual review of infection prevention policies and procedures not completed.
22VAC40-73-220-A: Information on private duty personnel services not obtained, reviewed, or notified in writing.
22VAC40-73-240-F: Volunteers did not attend orientation or documentation was unsigned or missing.
22VAC40-73-950-E: Semiannual review of emergency preparedness and response plan not implemented.
22VAC40-73-410-A: Orientation for new residents and legal representatives not provided or signed by resident.
22VAC40-73-680-M: Medication ordered for PRN administration was not available at the facility.
22VAC40-73-40-A: Failed to ensure compliance with facility’s own policies and procedures.
22VAC40-73-830-E: Written response to resident council recommendations not provided prior to next meeting.
22VAC40-73-620-B: Special diet oversight lacked certification that requirements were met.
22VAC40-73-290-B: Current on-site person in charge not posted conspicuously to residents and public.
22VAC40-73-460-B: Prompt response by staff to resident needs was not ensured.
22VAC40-73-970-A: Fire and emergency evacuation drills not conducted per Virginia Statewide Fire Prevention Code.
22VAC40-73-980-H: Emergency food and drinking water supply of at least 48 hours was not maintained on site.
22VAC40-73-700-1: Oxygen therapy orders did not include oxygen source as required.
22VAC40-73-250-D: Staff records lacked annual tuberculosis risk assessment documentation.
22VAC40-73-640-A: Medication management plan failed to ensure timely filling and refilling of prescriptions.
22VAC40-73-460-D: Failed to provide supervision of resident schedules, care, and activities including wandering prevention.
22VAC40-73-860-I: Hazardous materials were not kept in a locked area.
22VAC40-73-460-D: Failed to supervise resident schedules, care, and activities including wandering prevention.
22VAC40-73-320-A: Physical examination form lacked all required information and timely completion.
22VAC40-73-970-E: Fire and emergency evacuation drill records lacked required details and completeness.
Report Facts
Violations cited: 55
Distinct standards: 43
Inspections on page: 20
Inspections with violations: 14
Complaint visits: 4
Individual Reports
One document per inspection visit.
Inspection Report — Mar 10, 2022
Annual Inspection
Date: Mar 10, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care, including abuse prevention, care planning, accident prevention, medication management, and immunization documentation.
Findings
The facility was found deficient in multiple areas including failure to provide annual abuse training for staff, incomplete care plan reviews and revisions, inadequate supervision leading to resident falls and injuries, improper management of psychotropic medication orders, and failure to document and administer required vaccinations including pneumonia and COVID-19 vaccines.
Deficiencies (6)
Failure to implement abuse prevention policies and provide annual abuse training for two employees.
Failure to review and revise the care plan for one resident to include measurable objectives and timeframes.
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision, resulting in actual harm to one resident and potential harm to another.
Failure to implement gradual dose reductions and limit PRN psychotropic medication orders to 14 days without physician reevaluation for two residents.
Failure to provide and/or document pneumonia vaccination status and administration for two residents.
Failure to document COVID-19 vaccination status for two residents and failure to properly educate and document vaccination status for residents and staff.
Report Facts
Residents in survey sample: 32
Residents reviewed for immunizations: 5
Skin tear size: 7
Skin tear size: 6
Skin tear size: 0.1
Skin tear size: 3.2
Skin tear size: 3
Falls: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in abuse training deficiency and skin tear incident |
| LPN D | Licensed Practical Nurse | Named in abuse training deficiency and vaccination documentation interview |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse training, care plan, medication orders, and vaccination documentation |
| Administrator | Facility Administrator | Notified of findings during end of day meetings |
| LPN B | Licensed Practical Nurse | Interviewed about CNA information sources for resident transfers |
| CNA C | Certified Nursing Assistant | Interviewed about transfer incident resulting in skin tear |
| CNA B | Certified Nursing Assistant | Interviewed about how CNAs know resident transfer needs |
Inspection Report — Feb 27, 2020
Routine
Date: Feb 27, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, medication administration, abuse reporting, care planning, activity services, respiratory care, food safety, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to administer medications at preferred times, incomplete grievance procedures, delayed abuse reporting, failure to implement care plans, inadequate activity services, unsafe environment leading to resident falls, improper respiratory equipment storage, lack of dementia care plan, and food safety violations.
Deficiencies (13)
Failure to administer Resident #65's sleeping pill at her preferred time of 8:30 PM for 7 out of 22 administrations.
Failure to provide residents with grievance procedures including email addresses of pertinent agencies.
Failure to post grievance procedures including email addresses on facility walls.
Failure to timely report suspected abuse and submit follow-up reports for Resident #3.
Failure to implement care plans for Residents #60, #65, and #61 including fall prevention, medication timing, and activity planning.
Failure to provide individualized activity services for Resident #61.
Failure to develop a therapeutic diet care plan for Resident #28 despite documented swallowing difficulties and choking risk.
Failure to ensure call bell was within reach for Residents #60 and #8, resulting in a fall and fracture for Resident #60.
Failure to store respiratory equipment properly; sterile water for oxygen concentrator was open and dated months prior.
Failure to establish a dementia care plan for Resident #18 despite severe cognitive impairment.
Failure to ensure therapeutic diet recommendations from SLP, RD, and physician were provided and followed for Resident #28.
Failure to obtain temperatures for walk-in refrigerator and freezer for 2 days in January 2020.
Failure to properly label and date food items including tuna salad and hard boiled eggs in the kitchen refrigerator.
Report Facts
Medication administrations: 22
Late administrations: 7
Temperature log missing days: 2
Hard boiled eggs: 18
Call bell circuit trouble duration: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse G | Licensed Practical Nurse | Interviewed about medication administration timing policy |
| Administrator Employee A | Administrator | Notified of multiple findings including medication timing, grievance procedures, abuse reporting, care planning, and call bell issues |
| Director of Nursing Employee B | Director of Nursing | Interviewed regarding abuse reporting and Resident #3 incident |
| Registered Nurse B | Director of Acute Care Services | Interviewed about grievance procedure poster |
| Licensed Practical Nurse J | Licensed Practical Nurse | Responded to Resident #60 fall and wrote incident report |
| Employee D | Activities Leader | Interviewed about Resident #61 activity preferences and services |
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed about oxygen equipment use and removal |
| Licensed Practical Nurse I | Licensed Practical Nurse | Interviewed about Resident #8 call bell location |
| Employee F | Director of Food and Beverage | Interviewed about food safety and labeling issues |
Inspection Report — May 24, 2018
Routine
Date: May 24, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, activities of daily living care, and food safety in the nursing home.
Findings
The facility failed to conduct comprehensive Minimum Data Set assessments within 14 days after a significant change in condition for one resident, failed to provide adequate grooming care for three residents, and failed to store and prepare food in a sanitary manner, including wet-nesting pans, undated frozen food, and exposure of food to debris.
Deficiencies (3)
Failed to ensure comprehensive Minimum Data Set (MDS) assessments were conducted within 14 days after a significant change in condition for Resident #53.
Failed to provide grooming for numerous facial hairs on the chins of Residents #6 and #17 prior to it growing to approximately 1 inch in length; Resident #28 observed with very long facial hair.
Failed to store and prepare food in a sanitary manner, including wet-nesting pans, undated frozen food, sugar stored with scoop handle in container, and food exposed to debris hanging from ceiling.
Report Facts
Residents in survey sample: 19
Number of pans wet-nested: 15
Date of admission for Resident #53: Admission date not specified
BIMS score for Resident #53 on 2/20/2018: 14
BIMS score for Resident #53 on 4/29/2018: 8
Length of facial hair observed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Interviewed regarding MDS assessments and acknowledged failure to conduct significant change in status assessment |
| Unit Manager (RN-A) | Unit Manager | Interviewed about residents' facial hair and grooming documentation |
| Director of Nursing (Employee B) | Director of Nursing | Informed of findings regarding grooming and stated facility lacked policy on shaving women's chin hairs |
| Facility Administrator (Employee A) | Facility Administrator | Informed of findings regarding grooming and food safety |
| Dietary Services Manager (Administration - G) | Dietary Services Manager | Interviewed about wet-nesting of pans in kitchen |
| Chef (Administration - F) | Chef | Interviewed about food storage and contamination risks |
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