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:

Complaint Related: No

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure that each resident's physical examination contains all of the required information. Evidence: The physical examination for Resident #2, dated 11/18/20, was observed during the inspection. The physical examination form stated that the resident is allergic to: iodine-131, naproxen, tositumomab, Celebrex, Dyazide, and ACE inhibitors. The form did not list Resident #2's reactions to the allergens. The physical examination for Resident #4, dated 10/20/20, was observed during the inspection. The physical examination form stated that the resident is allergic to: gluten, lactose, milk related products, and NSAIDs. The resident's allergic reactions to NSAIDs was documented, but not the resident's reactions to the other allergens.
Plan of Correction:	Resident #2 and #4's reactions to allergens were reassessed and documented in their medical records. The RN Resident Care Director (RCD) and/or designee will perform a 100% audit of residents with allergies to confirm that reactions to allergens are documented in their medical records. The SNA and RCD will provide education to sales team members and coordinators regarding required documentation of resident's allergens and reactions in the initial H&P prior to move-in. 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.