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: Feb. 16, 2023

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:

An unannounced renewal inspection was conducted on 2/16/23 (8:00 AM ? 6:30 PM). At the time of entrance, 68 residents were in care. Meals, medication administration, and activities were observed. Building and grounds were inspected and records were reviewed. The sample size consisted of 10 resident records and five staff records. Violations were discussed and an exit meeting was held. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to ensure that medication management plan is implemented, to prevent the use of outdated medication. Evidence: The morning medication administration, for Resident #3, was observed during the inspection. The medication cart contained an expired bottle of Resident #3?s Midodrine, at the time of the medication cart inspection. The bottle of Midodrine expired in January 2023.
Plan of Correction:	There is no evidence that the expired medication was given to the resident since the new medication was being used. Medication carts were audited on 2/17/23 and 2/20/23 and there were no expired medications found in the carts. Refresher training on proper and timely disposal of expired medications was provided by Resident Care Director (RCD) on 2/22/23 for nursing staff. Resident Care Director and/or designee will perform weekly random audits of medication carts for 3 months to confirm that there are no expired medications. The Resident Care Director and/or designee will report the results of the medication carts audits to 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 actions 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.
Standard #:	22VAC40-73-660-B
Description:	Based on observation and documentation, the facility failed to limit medication storage to an out-of-sight place in the rooms of residents whose UAIs have indicated that the residents are capable of self-administering their medication. Evidence: Deep Sea Nasal Spray was observed to be unlocked and unattended, in the room of Resident #4 of the memory care unit. Resident #4?s UAI, dated 8/22/22, states that she needs staff assistance for medication administration.
Plan of Correction:	Resident #4 came with the medication when she came back from hospital and there is no evidence that she used the medication in her room. Nurse Practitioner assessed the resident #4 and there are no harms from the medications. Full house audit of the medications in residents? rooms was performed on 2/20/23 and there were no other findings reported. Refresher training on safe medication storage was provided by Resident Care Director (RCD) on 2/20/23 for care team. Weekly audits of one random section of the community for the next 3 months. The Resident Care Director and/or designee will report the results of the audits to 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 actions 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.
Standard #:	22VAC40-73-680-D
Description:	Based on observation and documentation, the facility failed to ensure that medications are administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice approved by the Virginia Board of Nursing. Evidence: Resident #3?s February Medication Administration Record (MAR) was observed during the inspection. The MAR stated that Resident #3?s Midodrine was administered on 2/5/23 (9 AM administration) when her blood pressure was 141/93 and on 2/14/23 (5 PM administration) when her blood pressure was 157/83. Resident #3?s Midodrine order calls for the medication to be held when the resident?s Systolic Blood Pressure (SBP) is greater than 130. Resident #11?s MAR was observed during the inspection. The MAR stated that Resident #11?s Amlodipine and Losartan were administered on 2/5/23, when the resident?s blood pressure was 113/68. Resident #11?s Amlodipine and Losartan orders call for the medications to be held if the resident?s systolic blood pressure is 120 or less, or if her diastolic blood pressure is 60 or less. tice outlines in the current medication aide curriculum
Plan of Correction:	Nursing continued to monitor any signs and/or symptoms of side-effects from the deficient practice for resident #3 and #11 and there were no issues identified or reported by the community's nursing team. Providers for resident #3 and resident #11 were informed of BP medication given outside of parameter and both providers stated that the risk associated with the B/P medications given was minimal. The Resident Care Director (RCD) performed 100% audit of residents who are on blood pressure medications with parameter (total 45 residents) and to confirm medications were given within the parameter. There were no other residents found with BP medications given outside the parameter. Resident Care Director provided refresher training on 2/22/23 for nursing staff regarding administering medications in accordance with physician orders including blood pressure medications with administration parameter and checking e-MARs prior to administration. Resident Care Director and/or designee will perform weekly random audits 5 residents with BP medication with parameter for 3 months of medication administration records to confirm compliance with physician orders. The Resident Care Director and/or designee will report the results of the medication administration record (EMAR) audits to 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.
Standard #:	22VAC40-73-680-M
Description:	Based on observation and interview, the facility failed to ensure that medications ordered for PRN administration are available and properly stored at the facility. Evidence: PRN Ativan Solution, for Resident #3, was not present during the medication cart inspection. The cart contained Ativan tablets, ordered for Resident #3, but not the Ativan solution.
Plan of Correction:	It was a transcription error from hospice provider. Hospice nurse wrote order for liquid Ativan but hospice MD sent script to pharmacy with Ativan tablet. Accordingly, the community had Ativan tablet only. Upon receipt of the deficiency, the Resident Care Director contacted hospice provider and clarified the order, which is Ativan tablet. Medication carts were audited for availability of prn medications on 2/17/23 and prn medications were available in medication carts. Refresher training on verification of medication orders including hospice orders was provided by Resident Care Director (RCD) on 2/22/23 for nursing staff. Resident Care Director and/or designee will perform weekly random audits 5 residents with prn medications for 3 months to confirm compliance with accuracy and availability of prn medications. The Resident Care Director and/or designee will report the results of the audits to 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 actions 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.