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: Sept. 24, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS ARTICLE 1 ? SUBJECTIVITY 63.2- (1) GENERAL PROVISIONS 22VAC40-80 COMPLAINT INVESTIGATION

Technical Assistance:

N/A

Comments:

Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 09/24/2024 regarding allegations in the area(s) of: RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS & RESIDENT CARE AND RELATED SERVICES. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/24/2024 12:15 PM to 2:05 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: 67 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: Meals in Special Care Unit. Additional Comments/Discussion: Staff interviews were conducted off-site via telephone. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that any major incident that has negatively affected or that threatens the health, life, safety and welfare of any resident was reported to the regional licensing office within 24 hours. Evidence: 1. A complaint was received on 09/24/2024 regarding resident accommodations and related provisions, as well as resident care and related services for Resident 1. 2. Resident 1?s record contains a progress note written by Staff 4 on 06/30/2024 at 7:32 AM that states ??EMT pronounce death of resident at 5:15 am?? 3. Staff 1 confirmed that Resident 1 was not on hospice and an initial incident report was not sent to the regional licensing office.
Plan of Correction:	With respect to the specific resident/situation cited: There is no evidence that the cited issue affected any specific resident(s). With respect to how the facility will identify residents/situations with the potential for the identified concerns: The community?s administrator performed 100% audit of all resident deaths this year to confirm the compliance with the regulation and the administrator submitted a FRI to DSS on 9/24/24 regarding one death on 9/14/24. There were no other issues noted from the audit. With respect to what systemic measures have been put into place to address the stated concern: The community?s administrator provided education to Assisted Living Coordinator, Reminiscence Coordinator, Resident Care Director, Activities and Volunteer Coordinator, and Certified Dietary Manager regarding the incident report guideline related to death of residents who are not under hospice services at the time of death. With respect to how the plan of correction will be monitored: The community?s administrator and/or designee will perform audit of all residents? deaths 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.
Standard #:	22VAC40-73-930-D
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that the Individualized Service Plan (ISP) specified a minimal frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated resident needs. Evidence: 1. Resident 1?s record contains an ISP, with a focus that states ?Inability to use signaling device with need for night safety checks? initiated on 09/23/2022 and revised on 03/13/2024. The goal states ?My safety needs will be met daily due to my inability to use my signaling device through the next review date. The interventions state ?I am unable to use my signaling device due to [psychosis] and require safety needs to be anticipated and met. I require night safety check due to inability to use my signaling device. 2. The ISP does not contain the minimum frequency of rounds to be completed due to the resident?s inability to use the signaling device.
Plan of Correction:	With respect to the specific resident/situation cited: There is no evidence that the cited issue affected any specific resident(s). With respect to how the facility will identify residents/situations with the potential for the identified concerns: The community?s Assisted Living Coordinator (ALC) and Reminiscence Coordinator (RC) performed 100% audit of ISP to confirm the compliance with regulation related to ISP on resident?s inability to use the signaling device and a minimal frequency of daily rounds. All residents found non-compliant with the regulation was corrected. With respect to what systemic measures have been put into place to address the stated concern: The community?s administrator provided education to Assisted Living Coordinator, Reminiscence Coordinator, Resident Care Director, Activities and Volunteer Coordinator, and Certified Dietary Manager regarding the regulation related to ISP on resident?s inability to use the signaling device and a minimal frequency of daily rounds. With respect to how the plan of correction will be monitored: The community?s administrator and/or designee will perform audit of random 3 ISPs 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.