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: May 15, 2024 and May 16, 2024

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STA TEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

N/A

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/15/2024: 9:30 AM to 5:00 PM 05/16/2024: 8:25 AM to 4:35 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 6 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: Meals, Activities, Medication Pass. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. 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. 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 Amanda Velasco, Licensing Inspector at (571) 510 2058 or by email at Amanda.Velasco@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-220-A
Description:	Based on private duty record review, the facility failed to ensure information on the type and frequency of the services to be delivered to the resident by private duty personnel was obtained in writing. Evidence: 1. The records of seven (7) private duty personnel were provided by Staff 1. 2. All seven (7) records did not contain written information on the type and frequency of services to be rendered. 3. Staff 1 confirmed the records did not contain documentation of the duties provided by the private duty personnel.
Plan of Correction:	A. With respect to the specific resident/situation cited: The Assisted Living Coordinator and the Reminiscence Coordinator will perform 100% audit of current PDAs in the community. (07/11/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Assisted Living Coordinator and the Reminiscence Coordinator will complete each PDA specific type and frequency of the services to be delivered. (07/11/2024) C. With respect to what systemic measures have been put into place to address the stated concern: The community?s administrator provided education for Assisted Living Coordinator and the Reminiscence Coordinator on PDA requirements. (05/16/2024) D. With respect to how the plan of correction will be monitored: The community?s administrator and/or designee will perform monthly audits PDA binder for the next 3 months to confirm the compliance with PDA requirements. The community?s administrator 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 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. (09/30/2024)
Standard #:	22VAC40-73-240-F
Description:	Based on volunteer record review and staff interview, the facility failed to ensure all volunteers, prior to beginning volunteer service, attended an orientation including information on their duties and responsibilities, resident rights, confidentiality, emergency procedures, infection control, the name of their supervisor, and reporting requirements. Evidence: 1. Volunteer records for Staff 10, 11, 12, 13, and 14 did not contain documentation of orientation or their assigned duties and responsibilities prior to beginning volunteer service. 2. Staff 4 confirmed the volunteer records were not completed.
Plan of Correction:	A. With respect to the specific resident/situation cited: The community?s Activities and Volunteer Coordinator (AVC) provided the community specific orientation to volunteer #10, #11, #12, #13 and #14. (06/19/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The AVC performed 100% audit of current volunteers in the community and completed community specific orientation program to all current volunteers, who did not have an evidence of the community specific orientation. (05/16/2024) C. With respect to what systemic measures have been put into place to address the stated concern: The community?s administrator provided education for Activities and Volunteer Coordinator on volunteer requirements and community specific orientation program prior to beginning volunteer services. (05/16/2024) D. With respect to how the plan of correction will be monitored: The community?s administrator and/or designee will perform monthly audits of volunteer binder for the next 3 month to confirm the compliance with volunteer requirements. The community?s administrator 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 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. (09/30/2024)
Standard #:	22VAC40-73-260-C
Description:	Based on direct observation and staff interview, the facility failed to ensure A listing of all staff who have current certification in first aid or CPR was posted in the facility so that the information is always readily available to all staff. Evidence: 1. A list of all staff with current certification in first aid or CPR was not posted in the facility. 2. Staff 1 confirmed the facility did not have a list posted.
Plan of Correction:	A. With respect to the specific resident/situation cited: Care team members? schedule was posted in the wellness office as a list for 1st Aid and CPR certified staff list. (06/24/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Since all care team members are 1st Aid and CPR certified, team member schedule can be used for the certified team members list. The community posted care team member schedule in Wellness office. (06/24/2024) C. With respect to what systemic measures have been put into place to address the stated concern: The community?s RCD, ALC and RC will continue to post the care team member schedule at Wellness office weekly and as needed in case of updates to be compliant with the regulation. (06/24/2024) D. With respect to how the plan of correction will be monitored: The community?s Administrator and/or designee will perform audit of schedule posting in wellness office weekly for the next 3 months to confirm the compliance with the regulation. The community?s Administrator 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 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. (09/30/2024)
Standard #:	22VAC40-73-350-C
Description:	Based on facility document review and staff interview, the assisted living facility failed to ensure that each resident or his legal representative is fully informed upon admission and annually, that he should exercise whatever due diligence he deems necessary with respect to information on any sex offenders registered, including how to obtain such information. Evidence: 1. Residents 1 (date of admission 010/26/2022), 2 (date of admission 02/06/2023), and 6?s (date of admission 11/01/2022) records did not contain an annual notification that he should exercise whatever due diligence he deems necessary with respect to information on any sex offenders registered, including how to obtain such information. 2. Staff 1 confirmed the annual notification had not been completed. 3. Resident 5?s (date of admission 4/05/2024) record did not contain notification that he should exercise whatever due diligence he deems necessary with respect to information on any sex offenders registered, including how to obtain such information upon admission. 4. Staff 1 confirmed the notification had not been completed upon admission.
Plan of Correction:	A. With respect to the specific resident/situation cited: Community?s ALC will provide information on any sex offenders registered, including how to obtain such information, for resident #1, #2, and #6. Community?s RC will provide information on any sex offenders registered, including how to obtain such information, for resident #5?s representative. (06/28/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The community will implement the annual review of sex offender information during ISP meetings. (05/31/2024) C. With respect to what systemic measures have been put into place to address the stated concern: The community?s administrator provided education for Director of Sales, Assisted Living Coordinator (ALC) and Reminiscence Coordinator (RC) on requirement of 22VAC40-73-350. (05/20/2024) D. With respect to how the plan of correction will be monitored: The community?s Administrator and/or designee will perform audit of random 3 residents? ISPs monthly for 3 months to confirm the compliance with the regulation. The community?s Administrator 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 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. (09/30/2024)
Standard #:	22VAC40-73-390-A
Description:	Based on facility document review, the facility failed to ensure that the written agreement/acknowledgment included financial arrangement for accommodations services and care such as the description of all accommodations, services, and care that the facility offers and any related charges and failed to clarify that the written agreement/acknowledgment included requirements to be imposed regarding the resident conduct other restrictions or special conditions. Evidence: 1. Staff 1 provided the current resident agreement dated as revised 10/2022. 2. On page 4, article III, section A states the fees as ?The resident will pay the fees indicated on Exhibit 1.? 3. Exhibit 1 is titled ?Your Suite and Fees? and states both the base fees for ?Assisted Living Suite? and ?Reminiscence Suite? and lists the following care levels: Assisted Living Select, Assisted Living Plus, Assisted Living Plus Plus, Reminiscence Program Fee, Reminiscence Plus, Reminiscence Plus Plus, Terrace Club Program Fee, Terrace Club Plus, and Enhanced Care. 4. Each care level did not include a description of all accommodations, services, and care that the facility offers. 5. Staff 1 provided the current resident agreement dated as revised 10/2022. 6. On page 2, article II, section B states: ?Smoking is not allowed in any resident suite. Smoking is only allowed in designated ?Smoking Areas.? Whether to designate any Smoking Areas is within the sole discretion of the Community. The Community may require residents to be supervised when smoking.? 7. Staff 1 confirmed that they are a non-smoking community and they do not permit smoking on the property in any location.
Plan of Correction:	A. With respect to the specific resident/situation cited: There is no evidence that the cited issue affected any specific resident(s). (05/16/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The community?s team will work with community?s regional and corporate office team to update the current residency agreement to be specific to the community. (07/24/2024) C. With respect to what systemic measures have been put into place to address the stated concern: The community will review new residency agreement when it is updated annually and confirm the compliance with the regulation. (07/24/2024) D. With respect to how the plan of correction will be monitored: The community?s administrator and/or designee will perform audit of new residency agreement(s) for the next 3 months to confirm the compliance with the regulation. The community?s administrator 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 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. (09/30/2024)
Standard #:	22VAC40-73-410-A
Description:	Based on resident record review and staff interview, the facility failed to ensure acknowledgment of having received the facility orientation was signed and dated by the resident and such documentation shall be kept in the resident's record. Evidence: 1. Resident 2 (date of admission 02/06/2023) and 5?s (date of admission 11/01/2022) records contained a facility orientation that was signed by the facility and the resident?s legal representative, but not the resident signature. 2. Staff 1 confirmed the facility orientation was signed by the legal representative and not the resident. 3. Resident 1?s (date of admission 10/26/2022) record did not contain an acknowledgement of the facility orientation. 4. Staff 1 confirmed they did not complete the facility orientation.
Plan of Correction:	A. With respect to the specific resident/situation cited: The community?s ALC and RC will provide resident #2 and #5 orientation to the community with signed acknowledgement. (07/05/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The community?s ALC and RC will perform 100% audit of new resident files since last survey and identify any resident agreement signed only by resident?s representative(s). Any issues identified will be corrected with orientation to the resident(s) with acknowledgement. (07/24/2024) C. With respect to what systemic measures have been put into place to address the stated concern: The community?s administrator provided education for Director of Sales, Assisted Living Coordinator and Reminiscence Coordinator on requirement of 22VAC40-73-410. (06/27/2024) D. With respect to how the plan of correction will be monitored: The community?s Administrator and/or designee will perform audit of each new resident agreement for 3 months to confirm the compliance with the regulation. The community?s Administrator 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 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. (09/30/2024)
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review and staff interview, the facility failed to ensure a new Uniform Assessment Instrument (UAI) was completed prior to admission, annually, or when there is a significant change in condition. Evidence: 1. Resident 6?s record contained a UAI dated on 10/26/2022 and re-assessed on 03/08/2023. 2. Staff 1 confirmed that Resident 6?s UAI had not been updated once the previous assessment is more than 12 months old.
Plan of Correction:	A. With respect to the specific resident/situation cited: The community?s Assisted Living Coordinator (ALC) immediately completed new UAI for resident #6. (05/29/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The community?s ALC and RC performed 100% audit of UAI and ISP to confirm the compliance with the regulation and there were no other findings. (06/06/2024) C. With respect to what systemic measures have been put into place to address the stated concern: Administrator provided education to Assisted Living Coordinator, Reminiscence Coordinator, Resident Care Director, Wellness Nurse and Activities and Volunteer Coordinator regarding the timeliness and completeness of the UAI and ISP. (05/18/2024) D. With respect to how the plan of correction will be monitored: The community?s administrator and/or designee will perform audit of random 3 UAIs and ISP monthly for 3 months to confirm the compliance with the regulation. The community?s administrator 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 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. (09/30/2024)
Standard #:	22VAC40-73-620-B
Description:	Based on facility document review and staff interview, the facility failed to ensure the special diet oversight was certified that the requirements of this subsection (22VAC40-73-620) were met including the date of oversight and identification of the residents for whom the oversight was provided. Evidence: 1. The facility?s special diet oversights completed on 09/15/2023, 01//11/2024, and 03/28/2024 did not contain a certification statement that the requirements of 22VAC40-73-620 were met. 2. Staff 1 confirmed the special diet oversight did not contain a certification statement that the requirements of 22VAC40-73-620 were met.
Plan of Correction:	A. With respect to the specific resident/situation cited: A Certification of Oversight of Special Diets was created, and the dietitian certified and signed the form per 22VAC40-73-620 of Standards for Licensed Assisted Living Facilities and obtained the signature on the Crandall form during the survey. (05/16/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The community?s administrator provided education for community?s Food Services Director and Certified Dietary Manager to ask Crandall dietitian to certify and sign the Crandall form per 22VAC40-73-620 of Standards for Licensed Assisted Living Facilities going forward. (05/16/2024) C. With respect to what systemic measures have been put into place to address the stated concern: The Certification of Oversight of Special Diets on the Crandall Form will be implemented going forward and community?s Food Services Director and/or Certified Dietary Manager will verify the compliance.(06/24/2024) D. With respect to how the plan of correction will be monitored: The Food Services Director and/or designee will perform audit of Crandall Form during their next visit in July to confirm the compliance with 22VAC40-73-620 of Standards for Licensed Assisted Living Facilities. (07/15/2024) The Food Services Director and/or designee will report the results of the compliance with 22VAC40-73-620 to the Quality Assurance and Performance Improvement Committee for the next 6 months. (07/15/2024) During and at the conclusion of the 6 months, the QAPI Committee will re-evaluate and initiate the necessary actions or extend the review period. (10/15/2024) 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. (10/15/2024)
Standard #:	22VAC40-73-680-K
Description:	Based on resident record review and staff interview, the facility has failed to obtain a detailed PRN medication order from the resident?s physician or other prescriber that include symptoms that indicate the use of the medication when medication aides administer the PRN medication. Evidence: 1. Resident 3 has an order for 02/17/2023 for LORazepam Oral Tablet 1 MG (Lorazepam). 2. The order states ?Give 1 tablet by mouth every 2 hours as needed for anxiety.? 3. Staff 1 confirmed the order does not have detailed symptoms that indicate the use of medication.
Plan of Correction:	A. With respect to the specific resident/situation cited: The community?s Resident Care Director (RCD) updated the order to reflect the symptoms for use of the prn medication for the resident identified. (05/20/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The RCD added specific symptoms on prn psychotropic medications orders for other residents to be compliant with the regulation. (05/20/2024) C. With respect to what systemic measures have been put into place to address the stated concern: The RCD and/or designee will add specific symptoms on prn psychotropic medications orders going forward. (05/20/2024) The RCD and/or designee will initiate education for nurses to include detailed symptoms on writing an order of prn psychotropic medications. (07/01/2024) D. With respect to how the plan of correction will be monitored: The community?s Resident Care Director and/or designee will perform audit of random 3 residents with prn medication weekly for the first month and then monthly for two months to confirm the compliance with the regulation. The community?s RCD 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 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. (09/30/2024)
Standard #:	22VAC40-73-950-E
Description:	Based on resident record review and staff interview, the facility failed to ensure semi-annual review on the emergency preparedness and response plan was conducted for all residents with emphasis placed on an individual's respective responsibilities. Evidence: 1. Resident 1?s (date of admission 10/26/2022) record did not contain review of emergency preparedness and response plan semi-annually. 2. Resident 1?s last dated review was 10/10/2022. 3. Staff 1 confirmed the semi-annual review had not been completed.
Plan of Correction:	A. With respect to the specific resident/situation cited: Community?s ALC will review the emergency preparedness and response plan with resident #1. (06/28/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The community implemented the semi-annual review of the community?s emergency preparedness and response plan with signature for all residents during semi-annual ISP meetings. (06/16/2024) C. With respect to what systemic measures have been put into place to address the stated concern: The semi-annual review for all residents continues to be done during semi-annual ISP meetings. (06/16/2024) The administrator educated team members including leadership team regarding the importance of semi-annual review of the community?s emergency preparedness and response plan and also reviewed the community?s plan during Town Hall on 6/25/24. D. With respect to how the plan of correction will be monitored: The community?s Administrator and/or designee will perform audit of random 3 residents monthly for 3 months to confirm the compliance with the regulation. The community?s Administrator 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 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. (09/30/2024)
Standard #:	22VAC40-73-960-B
Description:	Based on direct observation and staff interview, the facility failed to ensure a fire and emergency evacuation drawing was posted in a conspicuous place on each floor of each building used by residents containing primary and secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes, and fire extinguishers. Evidence: 1. It was observed by two licensing inspectors that the third-floor emergency evacuation drawing contained an image of a telephone. 2. There was no phone available on the third floor. 3. Staff 1 confirmed the evacuation drawing contained a phone that didn?t exist.
Plan of Correction:	A. With respect to the specific resident/situation cited: The fire and emergency evacuation drawings were all updated during the survey and informed the surveyor of the immediate correction. (05/16/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: 100% house audit of the telephone was conducted, and evacuation drawing was revised accordingly. (05/16/2024) C. With respect to what systemic measures have been put into place to address the stated concern: The community?s administrator provided education for key team members regarding importance of accurate evacuation plan and emergency numbers readily available on the community telephones. (05/16/2024) D. With respect to how the plan of correction will be monitored: The community?s administrator and/or designee will perform monthly audits of the community telephones and evacuation plans for the next 3 months. The community?s administrator 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. (09/30/2024)