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: March 24, 2022

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 3/24/22. At the time of entrance, 66 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. Areas of non-compliance are identified on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure that each staff person submits the results of a risk assessment, documenting the absence of tuberculosis in a communicable form, on or within seven days prior to their first day of work at the facility. The risk assessment shall be no older than 30 days. Evidence: The record for Staff #5, hired 10/4/21, was reviewed during the inspection. Staff #5's record contained a tuberculosis risk assessment, dated 5/7/21. The risk assessment was more than 30 days old, when Staff #5 was hired.
Plan of Correction:	The team member who was out of compliance received PPD on 3/29/22 and result was negative on 3/31/22. Audit of new hires in the last 12 months was done on 4/1/22 for TB compliance and there was no other team member found with non-compliance. HR team and clinic nurse were re-educated on TB policy on 3/30/22. HR team continues current Sunrise TB screening flow to maintain compliance with TM TB compliance. HR Manager will review new hire HR file to monitor compliance with TB. HR Manager 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 #:	22VAC40-73-320-B
Description:	Based on record review, the facility failed to ensure that a risk assessment for tuberculosis is completed annually on each resident. Evidence: The record for Resident #1 was observed during the inspection. The most recent tuberculosis risk assessment in Resident #1's record was dated 2/11/21. The risk assessment was more than a year old, at the time of the inspection. The record for Resident #9 was reviewed during the inspection. The most recent tuberculosis risk assessment in Resident #9's record was dated 1/29/21. The risk assessment was more than a year old, at the time of the inspection.
Plan of Correction:	TB screenings were completed on 3/30/22 for two residents identified during the inspection. Audit of all residents on TB screening compliance was conducted on 3/29/22. There were three more residents who needed annual TB screening in a timely manner and the screenings for them were completed on 3/30/22. All other residents were in compliance during the audit. RCD began providing education for team members regarding the requirement of timely TB screening for residents. Tracking log was created to maintain compliance with timely TB screening for all residents. Weekly audit of random five residents beginning week of 3/28/22 for 3 months to confirm compliance with the requirement. 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 #:	22VAC40-73-560-E
Description:	Based on observation, the facility failed to ensure that all resident records are kept in a locked area. Evidence: The memory care wellness office was observed to be unlocked and unattended, shortly after noon. Resident charts were observed in an unlocked cabinet, in the wellness office.
Plan of Correction:	Wellness Office doors were immediately set up to be automatically locked when it is closed. Both Wellness Offices were checked on 3/25/22 and made the door automatically locked when closed. RCD began providing education for team members regarding the importance of locking the Wellness Offices for medication and medical records security. Weekly audit of Wellness Office will be conducted beginning week of 3/28/22 for 3 months to confirm compliance with the requirement. 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 #:	22VAC40-73-660-A
Description:	Based on observation, the facility failed to ensure that a locked medicine cabinet, container, or compartment is used for storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility. Evidence: Allegra and sterile eye drops were observed on the dresser of Resident #2 of the memory care unit. The Uniform Assessment Instrument (UAI) for Resident #2, dated 3/8/22, states that the resident needs to have her medication administered/monitored by professional nursing staff. The memory care wellness office was found to be unlocked and unattended, shortly after noon. An open box, containing various medication packages, was observed under a desk in the office.
Plan of Correction:	OTC medications were immediately removed from the resident's room. Wellness Office doors were immediately set up to be automatically locked when it is closed. Family of the resident with medication in her room was educated on the importance of medication safety on 3/31/22. Both Wellness Offices were checked on 3/25/22 and made the door automatically locked when closed. Full house search for medications in residents' rooms was conducted on 3/29/22. There were no more medications found in residents' rooms. RCD began education for team members regarding the requirement of medications in resident room. RCD also began providing education to team members regarding the importance of locking the Wellness Offices for medication and medical records security. Residents and family members were educated about the requirements through weekly ED newsletter on 4/7/22 and the requirements will be also discussed during Resident Council on 4/19/22. Sales team continues to educate prospective residents and family members regarding the requirement during move-in process. Weekly audit of random three residents in Assisted Living Neighborhood and three residents in Reminiscence beginning week of 3/28/22 for 3 months to confirm compliance with the requirement. Weekly audit of Wellness Office will be conducted beginning week of 3/28/22 for 3 months to confirm compliance with the requirement. 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 #:	22VAC40-73-700-1
Description:	Based on observation and interview, the facility failed to ensure that safety precautions are met and maintained, when oxygen therapy is provided. Evidence: Resident #1's oxygen was observed to be in use, during the inspection. An oxygen sign was not posted on Resident #1's door. No oxygen order was found in Resident #1's record, during the inspection. Facility staff confirmed that the oxygen order was not present, during the inspection.
Plan of Correction:	Immediately after the identification of the lack of oxygen sign, community placed the oxygen sign on the door of the resident. Oxygen order was obtained for the resident by resident?s physician on 3/25/22. The order was sent to DSS inspector for confirmation. Community conducted an audit regarding residents with oxygen and all other residents have oxygen sign on the door on 3/28/22. There were four residents with oxygen tank in the room and all four of them had sign on the door. Audit of residents with oxygen was conducted on 3/28/22 and there were six residents with oxygen order. Four of them have oxygen tank in the room with door signs and the other two did not have oxygen tank as it is as needed basis. RCD began providing education for team members regarding the requirement of oxygen sign on the door when resident uses oxygen. RCD also began providing education for team members regarding the requirement of obtaining oxygen order when resident uses oxygen. RCD also began providing education for team members regarding the requirement of obtaining oxygen order when resident uses oxygen. Weekly audit of oxygen sign for residents on oxygen beginning 3/28/22 for 3 months to confirm compliance with the requirement. Weekly audit of oxygen order for residents on oxygen beginning 3/28/22 for 3 months to confirm compliance with the requirement. 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.