VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Belvoir Woods Health Care Center at The Fairfax
9160 Belvoir Woods Parkway
Fort belvoir, VA 22060
(703) 799-1200

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: Oct. 20, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. An initial inspection was initiated on 10/20/20 and concluded on 10/22/20. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 59. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four resident records, four staff records, medication administration records, local fire and health inspections, and other documentation submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on record review, the facility failed to ensure that medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Resident #2's September MAR (medication administration record) was reviewed during the inspection. Resident #2's record contained an order for Carvedilol, dated 5/6/20, that called for the resident to receive one 6.25mg tablet twice per day. The order stated that the medication is to be held, if Resident #2's B/P (blood pressure) is less than 110 or HR (heart rate) is less than 60. The MAR indicated that Resident #2 was administered Carvedilol on 9/14/20 (5 PM administration) when the resident's blood pressure was 106/76. The MAR also indicated that Resident #2 was administered Carvedilol on 9/17/20 (5 PM administration) when the resident's blood pressure was 102/68.
Plan of Correction:	Resident #2 was assessed by a nurse practitioner on 10/22/20 and there was no new order given. The NP wrote that the risk associated with the B/P medication given was deemed minimal. Resident #2 experienced no negative outcomes. Nursing staff will continue to monitor. The RN Resident Care Director (RCD) performed a 100% audit of residents who are on blood pressure medications with parameter (total 22 residents) and nurses are administering medications within the parameter as ordered by providers. The SNA and RCD provided one on one education to involved nursing staff on 10/23/20. Involved Nursing staff will be subject to a complete med pass observation to demonstrate appropriate administration of medication and to confirm compliance with physician's orders, parameters, and standards of practice. Resident Care Director and/or designee will perform weekly audits beginning 10/26/20 for 1 month and monthly for 2 months of medication administration records to confirm compliance with physician orders. The RCD and/or designee will conduct random medication observations beginning 10/26/20 weekly for 3 months to confirm medications are administered in accordance with physician orders with a focus on blood pressure medications and administration parameters. Issues identified will be addressed and resolved along with refresher training as indicated. The Resident Care Director and/or designee will report the results of the medication administration record (EMAR) audits and the medication pass observations at the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary action or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur.