Belvoir Woods Health Care Center at the Fairfax
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State Inspection History
State Inspections
Source: VA State Licensing Agency
Feb 26, 2026Routine
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: 02/26/2026, 9:30 a.m. to 5:00 p.m. Number of residents present at the facility at the beginning of the inspection: 69 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: 3, and 1 partial review. Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Activities, lunch, medication pass. Additional Comments/Discussion: 3 staff observations only 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. f 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Based on observation, the facility failed to ensure that when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision. Evidence: 1. During the inspection on 02/26/2026 at approximately 11:40 a.m., the LI toured the secure environment of the facility. The following observations were made in the hallway outside of resident rooms where active remodeling or repair services appeared to be in progress. At the time of observation, no staff members, maintenance personnel, or contractors were present in the area to supervise or secure the materials. The following items were observed accessible in the hallway: a. One orange ladder and one piece of drywall leaning against a laundry basket containing soiled bed sheets and a plastic trash bag with cleaning cloths. b. One white ceramic bathroom toilet positioned upright against the hallway wall. c. One tool bag containing tools, a set of knee pads, and a metal carpet knee-kicker tool. d. One upright vacuum and one caulking gun with a container of caulk. 2. Photos taken as evidence.
Based on record review and interview, the facility failed to ensure that a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain all required components. Evidence: 1. Resident 7?s physical examination report dated 05/12/2025 was missing ambulatory or non-ambulatory status. 2. During the onsite inspection on 02/26/2026, Staff 1 and staff 3 acknowledged LI?s findings.
Based on record review, the facility failed to ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. The record for resident 6, (admitted 10/10/2022); contained a risk assessment for TB dated 09/17/2025. 2. The record for resident 3, (admitted 10/01/2021) contained risk assessments for TB dated 09/12/2024 and for 09/08/2025. 3. Resident 6 and Resident 3?s assessments for TB were not consistent within the Virginia Department of Health?s assessment screening. The facility?s TB assessment form states, ?None of the above symptoms were noted?, but does not list or indicate what those symptoms were. Additionally, the facility?s TB assessment form states? No above risk factors noted? but does not list or indicate what those risk factors were. 4. During the onsite inspection on 02/26/2026, Staff 1, and staff 2 reviewed the LI?s findings.
Based on direct observation and interviews, the facility failed to ensure that each resident shall be dressed in clean clothing and be free of odors related to hygiene. Evidence: 1. On 02/26/2026 at approximately 12:10 p.m., the LI observed staff 4 administering medication to resident 5. Resident 5 was seated in a wheelchair. The LI observed several wet areas on the lap of the resident?s pants, as well as what appeared to be food and food stains on the clothing. Additionally, the LI observed what appeared to be a small piece of orange cheese on the upper portion of the resident?s shirt. The LI asked resident 5 for permission and removed the cheese piece from the resident?s shirt. 2. Staff 4 stated that resident 5 was on the way to lunch after receiving the medication. 3. During an interview, the LI discussed the observations with staff 1 and staff 2. Resident 5 appeared to be wearing clothing that was visibly wet and stained, with food present on the clothing and body, which appeared consistent with food remaining from breakfast, as the resident was being taken to lunch immediately following the medication pass.
Based on record review and interview, the facility failed to ensure the licensed health care professional identified the specific residents for whom the health care oversight was provided. Evidence: 1. Health Care Oversight dated 12/19/2025 to 06/08/2025 did not document the names of the residents for whom the oversight was provided. 2. During the onsite inspection on 02/26/2026, Staff 1 and Staff 2 acknowledged the LI?s findings.
Based on a tour of the building and staff interview, the facility failed to ensure that the rights and responsibilities of residents are posted conspicuously in a public place with correct information available to the public. Evidence: 1.During the onsite inspection on 02/26/2026, the LI observed that a list of Residents? Rights and Responsibilities was posted in the assisted living hallway in six wall frames. 2.The information displayed in wall frame number six contained incorrect contact information for the Virginia Department of Social Services Licensing Division?s Licensing Administrator. 3.During the onsite inspection on 02/26/2026, Staff 1 confirmed the LI?s findings.
Based on documentation and interview, the facility failed to implement the medication management plan to include that each resident's over-the-counter medications and supplements were labeled. Evidence: 1. The facility?s medication management plan states that, ?Non-prescription medications not labeled by the pharmacy are kept in the manufacturer?s original container. Nursing care center personnel may write the resident?s name on the container or label as long as the required information is not covered?. 2. On 02/26/2026, the LI observed the medication cart located in the safe secure unit. One bottle of extra-strength Tylenol, 500 mg tablets, was observed unlabeled, with no resident name. 3. During the onsite inspection on 02/26/2026, Staff 1 and staff 3 acknowledged the LI?s findings. 4. Photo evidence taken.
Based on direct observations and an interview during the medication cart audit, the facility failed to have any over-the-counter medication labeled with the resident's name or in a pharmacy-issued container until administered. Evidence: 1. On 02/26/2026, at approximately 12:28 p.m.,the LI observed a medication pass with staff 4 and conducted a medication cart audit. A bottle of extra-strength Tylenol, 500 mg tablets, was observed unlabeled with no identifiable information to indicate who it belonged to. 2. Staff 4 acknowledged there was no name or label on the bottle of Tylenol but stated it belonged to Resident 2. 3. Photo evidence taken.
Based on direct observation and staff interview, the facility failed to ensure that any operable window was effectively screened. Evidence: 1. During the facility tour on 02/26/2026, at approximately 11:05 a.m., the LI observed that the secure memory unit dining area window was operable and missing its window screen. 2. During the onsite inspection on 02/26/2026, Staff 1 confirmed the dining room window is missing a window screen. 3. Photo evidence obtained.
Jan 6, 2026Routine
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/06/2026, 11:00 a.m. to 2:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 12/29/2025, regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 65 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 4 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Breakfast Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017, or by email at Jacquelyn.Kabiri@DSS.virginia.gov.
Based on a review of resident records the facility failed to perform a six-month review of the appropriateness of continued residence in the memory care unit. Evidence: 1. Resident 2 was admitted to the secure facility on 04/05/2024. The most recent review determining the continued appropriateness of this placement was completed on 10/01/2024. 2. Staff 1 confirmed the date of resident 2?s most current continued appropriateness of placement.
Based on the record review, the facility failed to ensure that a report was submitted within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. On 12/26/2025, a potential resident-to-resident incident occurred at the facility that required eporting. The required report was not submitted to the Department of Social Services Licensing Division until 12/29/2025. 2. During an interview with the Licensing Inspector (LI), Staff 1 stated that the report was not submitted within the required timeframe.
Dec 12, 2025ComplaintCleanReport
Type of inspection: ?Complaint? Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/12/2025, 10:30a.m. to 11:30 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on (12/08/2025) regarding allegations in the area(s) of: Resident Care and Related Services and Staffing and Supervision. Number of residents present at the facility at the beginning of the inspection: 65 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: 2 Observations by licensing inspector: Activities Additional Comments/Discussion: None. 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. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Nov 6, 2025ComplaintCleanReport
Type of inspection: ?Complaint? Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/06/2025, 9:00a.m. to 11:00 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on (11/03/2025) regarding allegations in the area(s) of: Resident Care and Related Services and Staffing and Supervision. Number of residents present at the facility at the beginning of the inspection: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 6 Observations by licensing inspector: Activities and Lunch Additional Comments/Discussion: None. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Sep 2, 2025Routine
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/02/2025, 1:00 p.m. to 4:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 2 Self-reports were received by VDSS Division of Licensing on 08/20/2025 and 08/28/2025, regarding allegations in the area(s) of: Direct Care and Related Services, Staffing and supervision, Building and Grounds, and Additional Requirements for Facilities That Care for Adults with Serious Cognitive Impairment. Number of residents present at the facility at the beginning of the inspection: 109 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: None Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-reports of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the (complaint(s)/self-report) but identified during the course of the investigation can also 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Based on observation and interview, the facility failed to ensure doors that lead to unprotected areas be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates for residents residing in a safe, secure environment. Evidence: 1. On 08/21/2025 and 08/28/2025, the facility self-reported the following elopements due to a malfunctioning door on the safe, secure environment: Resident 1 on 08/21/2025 and Resident 2 on 08/28/2025. 2. On 09/02/2025, at approximately 1:26 p.m. the licensing inspector (LI) toured the facility to inspect all exit doors on the secure unit to include the exit door resident 1 and resident 2 eloped through 08/20/2025 and 08/28/2025. 3. During this tour, the exit door located in wing 1, with a sign labeled ?East exit Stair?, was noted to be a delayed egress door designed to open after pushing the middle handle for 15 seconds. The LI tested the handle for 15 seconds, 30 seconds, and 60 seconds, but the door did not open. Staff 1 also performed the same test with identical results. 4. During an interview with staff 1 and staff 3, it was confirmed that two identified exit doors within the safe, secure environment were malfunctioning, with one resulting in the elopement of resident 1 on 08/21/2025 and resident 2 on 08/28/2025, and the other not operating as a delayed egress door as designed. 5. A video and photos taken as evidence.
Jun 27, 2025RoutineCleanReport
Type of inspection: ?Monitoring? Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/27/2025, 10:00 A.M. to 12:15 A.M. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 06/09/2025 regarding allegations in the area(s) of: Resident Care and Related Services, Personnel. Number of residents present at the facility at the beginning of the inspection: 69 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:1 Number of interviews conducted with residents:1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Activities. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017, or by email at Jacquelyn.Kabiri@dss.virginia.gov
Sep 24, 2024Complaint
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
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.
Based on resident record review and staff interview, the facility failed to ensure that the Individualized Service Plan ( ISP
May 15, 2024Routine11Report
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
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.
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.
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.
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.
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.
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.
Based on resident record review and staff interview, the facility failed to ensure a new Uniform Assessment Instrument ( UAI
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.
Based on resident record review and staff interview, the facility has failed to obtain a detailed PRN
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.
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.
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EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.
Nearby Alternatives
Belvoir Woods Health Care Center at the Fairfax
< 1 miNursing Home · Fort Belvoir, VA
Greenspring Village
4.1 miNursing Home · Springfield, VA
Westminster at Lake Ridge
4.9 miNursing Home · Lake Ridge, VA
Aarondale Retirement and Assisted Living Community
6.8 miAssisted Living · Springfield, VA
George Washington Health & Rehabilitation
7.3 miNursing Home · Alexandria, VA
C&w Best Care, INC I
7.5 miAssisted Living · Bryans Road, MD