1 Inspection Summary
Inspection Reports Summary
Covers 16 inspections · Jan 2021 – Apr 2026Visit Reason
The page covers 16 inspections of Belvoir Woods Health Care Center at The Fairfax from January 7, 2021 to April 10, 2026, including routine, renewal, monitoring, and complaint investigations.
Complaint Details
Two inspections were prompted by complaints received by VDSS Division of Licensing regarding allegations in areas including Resident Care and Related Services and Staffing and Supervision. Investigations did not support the allegations of non-compliance but violations unrelated to complaints were cited.
Findings
Across that history VDSS cited 37 violations under 32 distinct standards. 10 of 16 visits ended with violations cited and 6 with none. 2 inspections were prompted by a complaint.
Deficiencies (37)
22VAC40-73-460-H: Failed to ensure personal assistance with bathing at least twice a week as needed.
22VAC40-73-320-A: Failed to ensure physical examination by independent physician with all required components.
22VAC40-73-490-D: Failed to ensure licensed health care professional identified specific residents for health care oversight.
22VAC40-73-1180-A: Failed to ensure harmful materials inaccessible to residents except under staff supervision.
22VAC40-73-680-G: Failed to have over-the-counter medication labeled with resident's name or in pharmacy container until administered.
22VAC40-73-640-A: Failed to implement medication management plan including labeling OTC medications and supplements.
22VAC40-73-320-B: Failed to ensure annual tuberculosis risk assessment completed on each resident.
22VAC40-73-460-I: Failed to ensure residents dressed in clean clothing and free of hygiene-related odors.
22VAC40-73-860-D: Failed to ensure any operable window was effectively screened.
22VAC40-73-550-F: Failed to post residents' rights and responsibilities conspicuously with correct information.
22VAC40-73-1110-B: Failed to perform six-month review of appropriateness of continued residence in memory care unit.
22VAC40-73-70-A: Failed to submit report within 24 hours of major incident negatively affecting resident.
22VAC40-73-1150-A: Failed to ensure doors to unprotected areas monitored or secured with devices conforming to codes.
22VAC40-73-680-K: Failed to obtain detailed PRN medication order including symptoms indicating use.
22VAC40-73-410-A: Failed to ensure resident signed and dated acknowledgment of facility orientation.
22VAC40-73-260-C: Failed to post list of staff with current certification in first aid or CPR.
22VAC40-73-950-E: Failed to ensure semi-annual review of emergency preparedness and response plan.
22VAC40-73-350-C: Failed to inform residents or representatives about sex offender information upon admission and annually.
22VAC40-73-960-B: Failed to post fire and emergency evacuation drawing with required details on each floor.
22VAC40-73-620-B: Failed to certify special diet oversight including date and residents identified.
22VAC40-73-240-F: Failed to ensure volunteers attended orientation including duties, resident rights, and reporting requirements.
22VAC40-73-220-A: Failed to obtain written information on type and frequency of services by private duty personnel.
22VAC40-73-390-A: Failed to include full description of accommodations, services, care, and conduct requirements in written agreement.
22VAC40-73-440-A: Failed to complete new Uniform Assessment Instrument prior to admission, annually, or with significant change.
22VAC40-73-680-M: Failed to ensure PRN medications are available and properly stored at the facility.
22VAC40-73-640-A: Failed to prevent use of outdated medication per medication management plan.
22VAC40-73-680-D: Failed to administer medications according to physician instructions and nursing standards.
22VAC40-73-660-B: Failed to limit medication storage to out-of-sight place for residents capable of self-administration.
22VAC40-73-930-D: Failed to specify minimal frequency of daily rounds in Individualized Service Plan for emergencies.
22VAC40-73-70-A: Failed to report major incident threatening resident health, life, safety within 24 hours.
22VAC40-73-680-D: Failed to administer medications in accordance with physician's instructions and nursing standards.
22VAC40-73-660-A: Failed to use locked medicine cabinet or compartment for medication storage administered by facility.
22VAC40-73-700-1: Failed to ensure safety precautions met and maintained when oxygen therapy is provided.
22VAC40-73-320-B: Failed to ensure annual tuberculosis risk assessment completed on each resident.
22VAC40-73-250-D: Failed to ensure staff submit tuberculosis risk assessment results within required timeframe.
22VAC40-73-560-E: Failed to keep all resident records in a locked area.
22VAC40-73-660-A: Failed to ensure locked storage for medications and dietary supplements administered by facility.
Report Facts
Violations cited: 37
Distinct standards: 32
Inspections on page: 16
Inspections with violations: 10
Complaint visits: 2
Employees mentioned
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