VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Providence of Fairfax
9490 Sprague Avenue
Fairfax, VA 22031
(571) 396-0500

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: Oct. 27, 2022 , Oct. 31, 2022 , Feb. 1, 2023 and Feb. 3, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the building on 10/27/2022 at 10:30 am and exited at 1:36 pm. LI entered the facility at 10:04 am on 10/31/2022 and exited at 12:20 pm. LI entered the facility at 9:28 am on 2/1/2023 and exited at 12:21 pm. LI entered the facility at 3:00pm and exited at 3:30pm on 2/3/2023. 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 8/31/2022 regarding allegations in the area(s) of resident care and related services. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 11 Observations by licensing inspector: LI walked the corridor on the memory care unit. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were resident care and related services. A violation notice was 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1110-B
Description:	Based upon a review of records, the facility failed to ensure that six months after placement of the resident in the safe, secure environment, and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident?s continued residence in the special care unit. Evidence: 1. The record of Resident 1, reviewed on 10/27/22 did not include documentation that the review for appropriateness of placement and continued residence in the special care unit was completed within the required six- month time frame. Documentation in progress notes verified that Resident 1 was admitted to the special care unit on 10/26/21. The six-month review of Resident 1?s appropriateness of placement was required to have been completed by 4/26/22.
Plan of Correction:	1. Corrective action for resident ? Point Click Care (PCC) glitch to auto-generate scheduled assessment identified. All continuous special unit assessments have been entered into PCC as a scheduled assessment. 2. Identifying other residents ? An audit of all residents? memory care residents completed. There were no additional findings related to this citation. 3. Systemic changes ? An audit of all residents? electronic charts will be conducted to ensure that a six-month safe placement review is assigned and completed timely. 4. Monitoring corrective actions ? The Resident Care Director, or designated person will audit the Assessment History report monthly until compliance is met. The results of this audit will be reported during the Safety Committee meeting monthly x 3 months for review and recommendations. 3. Date correction action completed ? The community?s date of alleged compliance is September 5th, 2023.
Standard #:	22VAC40-73-70-A
Description:	Based upon a review of records, 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 any resident: Evidence: 1.Progress notes dated 2/22/2022 at approximately 4:34 pm documented an incident in which Resident 1 attacked staff. Staff called 911 to request assistance of 911 team members to ?help de-escalate the situation.?
Plan of Correction:	1. Corrective actions and systemic changes ? The management team has been educated on identifying state reportable and timeframes ? ED or designated person will report any major incident that has the potential to or has negatively affected the health, safety, or welfare of any resident to the regional licensing office within 24 hours of observance. ? All staff members will be educated on identifying aggressive behavior(s) and de-escalating techniques. 2. Monitoring corrective actions ? The Resident Care Director, Memory Care Director, or designated person to completed random retention checks weekly and follow up on any subsequent findings. The results of this audit will be reported during the Safety Committee meeting monthly x 3 months for review and recommendations. 3. Date correction action completed ? The community?s date of alleged compliance is September 5th, 2023
Standard #:	22VAC40-73-460-A
Description:	Based upon a review of records and interviews, the facility failed to ensure the health, safety, and well-being of the residents. Evidence: 1. On 10/21/2022 LI interviewed a collateral #1 who stated that on 8/30/22 at approximately 4:00pm they had observed Resident #1 in the room of Resident #2 on multiple occasions. Collateral #1 stated that on 8/30/22, they observed the following: ? Resident #1 enter the room of Resident #2. ? Resident #1 wrestle for the cane from Resident. Resident #2 was thrown to the ground by Resident #1, then Collateral #1 heard Resident #2 scream. ? Resident #1 take his left foot and hit Resident #2?s right leg, and then hitting Resident #2 with the cane five to seven times. 2. Progress notes written on 8/30/2022 documented that after the incident between Resident #1 and Resident #2 staff assessed Resident #2 for injuries. Resident #2 complained of leg pain and was sent by the facility to Inova Fairfax Hospital. The progress notes written on 8/30/23 also documented that at approximately 11:00 pm on 8/30/2022, Resident #2?s responsible party notified the facility that Resident #2 had suffered a fractured hip. 3. During an interview conducted on 2/1/2023 Staff #5 stated that: On 8/30/2022, she was assisting a resident with eating and observed Resident #1 walking around the unit. ? At approximately 4 pm on 8/30/2022, she lost sight of Resident when she went to empty trash and then began searching resident rooms for Resident #1 ?starting with room 2102.? ? Resident #1 passed her in the hallway carrying a cane. ? She then went to Resident #2?s room to check on her and found her ?lying on the floor crying?. ? She then called her co-worker for help and contacted the charge nurse. LI asked Staff #5 if she knew of any previous aggressive behaviors involving Resident #1. Staff #5 stated that Resident #1 ?can be very, very aggressive, and you have to watch him when he is not in his room and that resident?s doors to their rooms are locked when he is walking around. ? 4. During an interview with Staff #1 they stated that the daughter of Resident #2 had previously reported her concerns to the facility regarding the fact that during previous video calls she was had with Resident #1 she observed Resident #1 wander into the room of Resident #2 and sit on the Resident #2?s bed. 5. The Individualized Service Plan (ISP) for Resident #2 documented that on 8/31/22 focus of post-trauma care was added to the ISP with goals of ?member will be able to express and discuss negative emotions, and member will exhibit reduced levels of fear and anxiety.? The intervention/tasks associated with the post-trauma care on the ISP are as follows: Caregivers will establish and sustain a trusting relationship with member by listening and demonstrating warmth and express understanding. Member has a private aid caregiver who comes in to accompany (provides emotional support) member in the afternoon daily. Staff will maintain a calm, non-threatening behavior and environment while working with member. Caregivers will assist member with reassurance and comfort as needed. Caregivers will conduct hourly checks for assurance and safety.
Plan of Correction:	This plan of correction is submitted as required under State and/or Federal law. The submission of this Plan of Correction does not constitute an admission on the part of the Community as to the accuracy of the surveyors? findings or the conclusions drawn therefrom. Submission of this Plan of Correction also does not constitute an admission that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Community?s policies and procedures should be considered subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence, corresponding state rules of civil procedure and should be inadmissible in any proceeding on that basis. The Community submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the Community or any employee, agent, officer, director, attorney, or shareholder of the Community or affiliated companies. 1. Corrective action for resident ? Resident #1 and resident #2 no longer reside in the community. 2. Identifying other resident ? Prior to admissions nursing manger(s) will review potential move in?s progress notes including physician notes, psychiatric notes (if applicable), UAIs and other clinical documents to determine appropriate placement and level of care. ? All new move-ins will be observed for behavioral patterns every shift for the first 30-days. Any noted behaviors will be communicated to providers and care planned with recommended interventions. 3. Systemic changes ? Clinical team will collaborate with member, RP/POA, and interdisciplinary team (s) to ensure safety and proper level of care is maintained for all residents throughout their stay. All correspondence will be recorded in resident?s charts accordingly. 4. Monitoring corrective changes ? The Resident Care Director or designee will complete audits of all behavioral orders on all new admissions weekly x first 30 days and monthly thereafter on residents to assess compliance and follow up on any subsequent findings. The results of this audit will be reported during the Safety Committee meeting monthly x 3 months for review and recommendations. 5. Date correction action completed ? The community?s date of alleged compliance is September 5th, 2023.