Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Belvoir Woods Health Care Center At The Fairfax during CMS and state inspections, most recent first.
Staff failed to ensure residents knew where to find contact information for the State Survey Agency and the State LTC Ombudsman. Required lists of names, mailing/email addresses, and phone numbers were posted behind the concierge desk in an area not accessible to residents, and no other signage was present on the unit. During a Resident Council meeting, all residents present were unable to identify the location of this information and were unaware of their right to file complaints with the State or Ombudsman. Later, two residents taken to see the posting stated they had not known it was there, while the concierge reported residents must ask for the information and that none had done so during her tenure.
Staff failed to ensure that required contact information for the State Survey Agency, State licensure office, and the State LTC Ombudsman was posted in an accessible location. The information was placed behind a concierge desk in an area where residents are not allowed, and no other signage was posted on the affected floor. During a Resident Council meeting, all residents present were unable to identify where this information was located and were unaware of their right to file complaints with these agencies. When two residents in wheelchairs were later shown the sign, they could not see it from their position in front of the desk while staff pointed to the posting behind the desk.
Staff failed to update person-centered care plans for several residents after significant changes in condition and services. One resident with severe cognitive impairment and multiple chronic conditions was admitted to hospice, but this was not added to the care plan. Another resident with severe cognitive impairment, diabetes, hypertension with orthostatic hypotension, and impaired mobility had an unwitnessed fall from bed to a fall mat and recurrent low BP episodes, yet the fall and orthostatic hypotension were not incorporated into the care plan. A third resident with vascular dementia, malnutrition, and hearing loss did not tolerate dentures or a hearing aid and was repeatedly observed without them, struggling to chew and communicate, but this intolerance was not reflected in the care plan. In addition, a cognitively intact resident with atrial fibrillation, CKD stage 4, and heart failure had a care plan that continued to list hospice services even though hospice had been discontinued, and this change was not updated in the care plan.
Staff failed to provide and coordinate required bathing and hygiene assistance for four dependent residents. One cognitively intact resident with a history of falls reported only receiving basin baths and having to request showers, despite a care plan and ADL schedule for twice-weekly showers, and the ADON acknowledged showers were not documented. Another resident with a femur fracture stated he received his first thorough shower only on the survey day, although he was scheduled for twice-weekly showers and his room board lacked shower-day postings. A cognitively impaired resident dependent for self-care was repeatedly observed with oily hair, dry rough skin, and later an offensive odor, while records only showed two refusals of showers/tub baths and no alternative bathing. A fourth cognitively intact resident requiring substantial assistance for bathing reported she had not taken showers or tub baths because she believed hospital instructions about dressings prohibited immersion, and she stated no one at the facility had educated her that bandages could be removed and reapplied for bathing, despite documentation indicating she was receiving scheduled showers or tub baths.
The facility’s QAPI/QAA program failed to identify multiple systemic problems, focusing only on falls, pressure ulcers, and transcription errors while missing significant issues in ADLs, care planning, and the environment. Surveyors found that several dependent residents were not receiving regular full-body baths, with observations of oily hair, scaly skin, body odor, and complaints about not getting showers or hair washed, corroborated by shower/tub documentation. Review of person-centered care plans for sampled residents showed they were not being routinely reviewed and revised as residents’ conditions changed. Environmental observations revealed resident rooms that were not safe, clean, comfortable, or homelike, including a room with ongoing heating problems where a resident reported being cold at night, and more than 15 rooms with damaged or deteriorated wall surfaces. These system failures had not been identified or brought to the QAPI team by facility staff.
Staff failed to maintain a comfortable and homelike environment for two residents when one cognitively intact resident repeatedly reported her room was cold despite prior complaints to maintenance and ongoing issues with the PTAC heat setting, and another resident with severe cognitive impairment was found in a room with scattered personal belongings and torn wallpaper behind the bed, despite her stated preference for stored belongings and wall repair. Staff interviews revealed that a CNA responded to cold complaints only by providing extra blankets, the maintenance engineer acknowledged incorrectly switching the PTAC from cold to heat, and the assistant engineer reported multiple rooms with unrepaired accent walls damaged during bed moves, while the DON stated nursing was responsible for proper storage of residents’ belongings.
A resident with osteomyelitis, CHF, and atrial fibrillation was admitted on apixaban 2.5 mg PO BID. A subsequent physician order for apixaban 2.5 mg was incorrectly transcribed as 12.5 mg PO BID, and a nurse later signed off administration of the erroneous 12.5 mg dose. The resident had recently reported new left leg swelling and redness and had a negative ultrasound for DVT, but there was no documented physician order to increase apixaban. The ADON reported that the nurse who transcribed the order mistakenly changed the dose and that the nurse administering the medication did not recognize that the new dose would require five tablets instead of one, resulting in a documented medication order and MAR entry that did not meet professional standards of quality.
Staff failed to prevent the development of a sacral stage 3 pressure ulcer in a cognitively impaired, highly dependent resident with multiple comorbidities and documented risk for impaired skin integrity. The care plan called for monitoring pressure areas, turning and positioning, and assisting the resident to bed during the day for pressure relief, but observations showed the resident remaining in a wheelchair for many hours on multiple days, largely to accommodate a spouse’s preference for dining room meals. Skin assessments progressed from no issues to MASD on the sacrum and then to an open sacral wound, which was later staged by a wound care physician as a stage 3 pressure ulcer of pressure etiology. The DON reported relying on staff assurances that weight shifting occurred in the wheelchair, and there was no indication that the responsible party was educated about the need for pressure offloading, while the resident was also observed receiving no encouragement or assistance with meals.
A resident with diabetes, orthostatic hypotension, impaired mobility, and severely impaired cognition (BIMS 5/15) fell from bed to floor while a CNA was providing incontinence care. The resident had a history of intolerance to sitting up, low BP episodes, and resistance to sitting at the edge of the bed, but resistance to care was not included in the care plan. During the incident, the resident resisted care, tried to get out of bed, and slid to the floor, requiring two staff to return her to bed. The DON later stated the CNA should have stopped care when resistance occurred, reminded the resident she needed assistance to get out of bed, ensured safety, and then reapproached, indicating that adequate supervision and assistance were not provided to prevent the fall.
A resident with a femur fracture, history of falls, unsteadiness, and occasional incontinence, who was cognitively intact and required assistance with transfers and toileting, repeatedly requested a bedside urinal but was not provided one. Over several observations, surveyors found the urinal stored in a bag in the bathroom rather than at the bedside, while the resident stated he had not received the requested urinal. CNAs reported that they typically did not allow bedside urinals, citing infection control and a practice of keeping urinals in the bathroom and instructing residents to use the call light for assistance, whereas an LPN stated that residents who cannot transfer independently are allowed bedside urinals to help prevent falls. Leadership later acknowledged there was no policy on bedside urinals and that the resident could have one if able to use it.
An LPN was observed administering Benzonatate 100 mg from a medication card whose pharmacy-printed label had been altered by handwriting a new dosing interval over the original directions. Physician orders for this medication had changed multiple times from PRN dosing to scheduled dosing, and pharmacy instructions directed staff to use the on-hand PRN supply until a new card arrived. Facility policy required nurses to apply a separate "direction change" or similar label when prescriber directions changed, rather than altering the original pharmacy label, but this procedure was not followed. The DON later stated that nurses are expected to follow the medication labeling policy, and the findings were presented to the administrative team.
A resident with severe cognitive impairment and multiple diagnoses was admitted to hospice for end-of-life care related to senile degeneration of the brain, with a care plan calling for coordinated hospice services and communication. However, staff reported not seeing hospice aides provide services and only occasional visits by a nurse, and a review of the paper chart found no hospice admission paperwork, care plan, or visit notes. As a result, details about hospice services, scheduling, communication processes, and triggers for contacting hospice were not available in the facility’s records, and leadership later acknowledged this non-compliance.
Facility staff did not maintain complete documentation of staff COVID-19 education and vaccination status. The HR manager reported that there was no documentation for long-term employees and that only new hires initialed an orientation form indicating they received COVID-19 education, but could not produce the actual education materials for two selected new hires. The HR manager later provided the facility’s COVID-19 preparedness and response plan as the education but was unable to show records that all staff had been offered the COVID-19 vaccine or that their vaccination status was documented.
A resident with an L4 wedge compression fracture and intact cognition was observed in bed with the call bell on the floor and not within reach while needing assistance to clean spilled water from his shirt. The resident reported having fallen the previous night after pressing the call bell without receiving a response and then attempting to pull the curtain, resulting in a fall onto his left side. Observations showed the call bell remained on the floor for an extended period until a CNA entered the room and placed it at the bedside, despite stating that resident rounds were done every 15 minutes. The Administrator later stated she had not been informed of this issue.
Failure to Inform Residents of Location of State and Ombudsman Contact Information
Penalty
Summary
Facility staff failed to ensure that residents were informed of the location of contact information for the State Survey Agency and the State Long-Term Care Ombudsman program. During an observation of the third floor, the required list of names, mailing and email addresses, and telephone numbers for the State licensure office and the State Long-Term Care Ombudsman was found posted behind the concierge’s desk on the wall, in a location inaccessible to residents. No other signage with this required information was posted on the third floor. At a Resident Council meeting, all 10 residents present were unable to identify where the contact information for the State licensure office and the State Long-Term Care Ombudsman was located and were unaware of their right to file a complaint with these entities. After the meeting, the Activities Director escorted two residents to view the Ombudsman information, and both stated they did not know it was posted there. Concierge staff reported that residents must ask for the information and phone numbers if they need them and that no resident had requested this information during the five years she had worked at the facility. The Activities Director reported there was another copy of the information outside her office on the second floor for assisted living residents. Leadership, including the DON, ADON, and Administrator, were later informed of these findings.
Required Ombudsman and State Agency Contact Information Not Accessible to Residents
Penalty
Summary
Facility staff failed to post the required list of names, mailing and email addresses, and telephone numbers for the State Survey Agency, State licensure office, and the Office of the State Long-Term Care Ombudsman in a location accessible to all residents. During an observation of the third floor, this information was found posted behind the concierge’s desk on the wall, an area where residents are not allowed. No other signage with the required information was posted on the third floor. Concierge #2 stated that residents are not permitted behind the desk, that the door to the dining room behind the desk is kept locked so residents cannot go behind the desk, and that residents must ask for the information and phone numbers if they need them. Concierge #2 also reported that in five years of employment, no resident had requested this information. During a Resident Council meeting, all 10 residents present were unable to identify where the required information was located and were unaware that they had the right to file a complaint with the State licensure office or the State Long-Term Care Ombudsman. After the meeting, the Activities Director took two residents in wheelchairs to view the Ombudsman information; they were positioned in front of the concierge’s desk while the Activities Director pointed to the sign behind the desk and explained its contents. From their position, the two residents were unable to see the information on the signage. The Activities Director stated there was another copy of the information outside her office on the second floor for assisted living residents. The Administrator later stated that the Activities Director hands out cards with Ombudsman information from time to time and that the Ombudsman conducts rounds in the facility.
Failure to Review and Revise Person-Centered Care Plans After Changes in Condition and Services
Penalty
Summary
Facility staff failed to review and revise person-centered care plans for multiple residents following significant changes in condition or services. One resident with Alzheimer's disease, heart failure, and diabetes, who had severely impaired cognition per a BIMS score of 3/15, was admitted to hospice services on 3/8/26 after a documented decline including decreased oral intake and episodes of MASD. Despite this, the active care plan with a target date of 3/26/26 did not include the resident's election and admission to hospice services. Another resident with diabetes, hypertension with episodes of orthostatic hypotension, and impaired mobility and self-care after lumbar spine fusion had a BIMS score of 5/15, indicating severely impaired decision-making. This resident experienced an unwitnessed fall from the bed to the fall mat on 3/13/26, and nursing notes documented the fall and stated that no changes to the care plan were needed. The active care plan with a target date of 6/17/26 did not address the fall or the resident's episodes of orthostatic hypotension, despite the Rehab Director reporting that the resident was unable to tolerate therapy, resisted sitting up, had low blood pressure episodes, felt ill when upright, and vomited. A third resident with vascular dementia, mild protein-calorie malnutrition, hearing loss, and severely impaired cognition (BIMS 0/15) had an MDS indicating minimal hearing difficulty, and the care plan stated the resident required assistance with dentures. However, the active care plan with a target date of 5/2/26 did not document that the resident did not tolerate dentures and a hearing aid. During multiple survey visits, the resident was consistently observed without dentures, placing unchewed food into napkins, and having extreme difficulty communicating due to inability to hear. A private duty sitter reported that the resident's son had said it was acceptable for the resident not to wear dentures and the hearing aid because the resident repeatedly removed and discarded them. Additionally, another resident with intact cognition (BIMS 15/15) and diagnoses including atrial fibrillation, stage 4 chronic kidney disease, and heart failure had an active care plan with a target date of 6/5/26 that incorrectly stated the resident was receiving hospice services, even though a nutrition note documented discharge from hospice on 3/4/25 and the DON confirmed the resident was no longer on hospice.
Failure to Provide and Coordinate Scheduled Bathing and Hygiene Assistance
Penalty
Summary
Facility staff failed to provide necessary activities of daily living (ADL) assistance, specifically bathing and hair washing, to multiple dependent residents. One resident with a history of repeated falls and unsteadiness on feet was cognitively intact and had a care plan emphasizing her preference and goal to increase functional ability with bathing, including choosing between a tub bath, shower, bed bath, or sponge bath. She reported that staff were relying on her to ask for showers, that she believed she had designated shower days, and that she had instead been taking basin baths and using washcloths to run through her hair. ADL records showed scheduled showers twice weekly, but documentation reflected self-bathing on one date and "NA" on another, and the ADON later acknowledged that showers were not documented for this resident and that her preference for daytime showers had not been aligned with the existing schedule. Another resident admitted with a right intertrochanteric femur fracture, and diagnoses including repeated falls and unsteadiness on feet, reported that he received his first shower on the morning of the survey interview, stating that it was the first thorough washing since admission. He stated that staff had not bathed him in the shower room or in bed prior to that day, although he had been able to perform limited self-care such as shaving, wiping himself with a washcloth, and brushing his teeth. Staff interviews indicated that showers or refusals were to be documented in the electronic record, that there was a set shower schedule, and that shower days should be posted on room boards and in CNA computers. The resident’s room board did not list shower days, although an LPN confirmed that the resident was scheduled for showers twice weekly on the day shift. ADL documentation showed the first recorded shower on a date consistent with the resident’s report and an earlier scheduled date marked as "NA." A third resident with Alzheimer’s dementia and paroxysmal atrial fibrillation, who was severely cognitively impaired and dependent or requiring substantial assistance for most self-care tasks including showering/bathing, was observed on two separate days with oily, flat hair, dry rough skin on the face, and later with an offensive odor. Her care plan included a goal to increase functional ability with bathing and interventions allowing her to choose the type of bath while requiring substantial/maximal assistance. A family member reported that her hair had not been washed for weeks and that he planned to ensure her hair was washed before transfer to another facility. Bathing records showed refusals of showers/tub baths on two dates, with no documentation of alternative bathing or hair washing. A fourth resident, cognitively intact but requiring substantial/maximal assistance with showering/bathing and several other ADLs, had a care plan goal to increase functional ability with bathing and interventions emphasizing her choice of bathing method. She was observed with multiple scabs on her arms and legs, dry and scaly skin on her arms, legs, and face, and hair that had been washed and set at the beauty shop that day. She stated she was not taking showers or tub baths because hospital staff had told her she could not immerse in water due to dressings, and she reported that no one at the facility had informed her that bandages could be removed and reapplied to allow bathing. CNA interview indicated that every resident received showers or tub baths as scheduled, and documentation stated that this resident was receiving showers or tub baths according to her schedule, but the resident’s own account and the DON’s subsequent interview confirmed that she had not been receiving showers or tub baths at the facility due to her understanding of the hospital’s instructions and lack of education from facility staff.
Failure of QAPI Program to Identify Systemic Issues in ADLs, Care Planning, and Environment
Penalty
Summary
The deficiency involves the facility’s failure to operate an effective QAPI/QAA program that identifies and addresses failed systems. During an interview, the Administrator stated that the QAPI committee relied on data from the 5-star report, Resident Council meetings, grievances, families, residents, and the IDT, and that current focus areas included falls, pressure ulcers, and transcription errors. However, during the survey, three additional system failures were identified by surveyors—Activities of Daily Living (ADLs) related to showers/tub baths, ongoing review and revision of person-centered care plans, and maintaining a safe, clean, comfortable, and homelike environment—that had not been recognized or presented to the QAPI team by facility staff. Surveyors found that several dependent residents were not receiving regular full-body baths, specifically showers or tub baths, and observations revealed residents with oily hair, scaly skin, and body odor, with some residents reporting not receiving showers or hair washing. Review of shower/tub bath documentation confirmed that residents were not receiving regular full-body bathing. Review of person-centered care plans for all sampled residents showed a pattern of plans not being reviewed and revised on an ongoing basis as residents’ conditions improved or deteriorated. Environmental observations identified resident rooms that were not safe, clean, comfortable, or homelike, including one room with ongoing heating issues where a resident reported being cold on several nights, and more than 15 rooms with walls needing painting or with torn wallpaper and exposed wallboards. These issues were not identified by the facility’s QAPI process, and when given an opportunity, the leadership team did not provide additional information to demonstrate that these system failures had been recognized or addressed through QAPI/QAA activities.
Failure to Maintain Comfortable Room Temperatures and Homelike Room Conditions
Penalty
Summary
Facility staff failed to ensure a safe, comfortable, and homelike environment for two residents by not adequately addressing room temperature concerns and room condition issues. One cognitively intact resident with chronic kidney disease and neuralgia reported ongoing problems with her room being cold, stating during a resident meeting that maintenance had been informed but the issue was not fixed. Resident council notes documented a prior grievance from this resident about temperature, but it referenced common areas rather than her specific room. On multiple occasions, the resident reported her room felt cold, including one instance where she stated she thought she was going to freeze because she had not had heat in her room since the previous day, despite the maintenance engineer later measuring the room temperature in the low 70s Fahrenheit and acknowledging that the PTAC unit had been incorrectly switched from cold to heat. Another resident with atrial fibrillation and chronic venous insufficiency, who had severely impaired cognitive abilities per a recent MDS assessment, was observed in bed stating she did not feel well, though she could not specify what was wrong. Her room was observed to be cluttered, with personal belongings scattered on the bedside table, chair, and overbed table, and the wall behind her bed had torn wallpaper. When asked, the resident expressed a preference for having her belongings stored and for the wall beside her bed to be repaired. The DON later stated that nursing was responsible for ensuring residents' personal belongings were stored appropriately. Interviews with staff further described the circumstances contributing to these deficiencies. A CNA reported that the resident with temperature concerns had complained of being cold at night and was given two blankets. The maintenance engineer explained that the PTAC unit required switching between heat and cold modes and admitted he had switched it incorrectly, contributing to the resident’s perception of inadequate heat. The assistant engineer reported that many rooms had accent walls needing repair and attributed wall damage to direct care staff tearing walls when moving beds, noting that repairs had not been completed because residents would need to be moved out of rooms for the work. These actions and inactions resulted in residents not consistently experiencing a comfortable temperature or a homelike, well-maintained room environment.
Medication Transcription Error for Anticoagulant Order
Penalty
Summary
Facility staff failed to ensure that a medication order for an anticoagulant met professional standards of quality when a nurse inaccurately transcribed a physician’s order for apixaban. The resident involved had been admitted after an acute care hospital stay with diagnoses including right 5th finger osteomyelitis/septic arthritis requiring IV therapy, congestive heart failure, and atrial fibrillation, and had a BIMS score of 11/15 indicating moderately impaired cognitive abilities for daily decision-making. The resident was admitted with an order for apixaban 2.5 mg by mouth twice daily. A new order was written on 3/13/26 for apixaban 2.5 mg, but it was transcribed in the record as “Give 12.5 mg by mouth twice daily,” changing the dose from 2.5 mg to 12.5 mg. On 3/14/26, a nurse signed off that 12.5 mg of apixaban had been administered, reflecting the incorrect transcribed dose. The physician’s progress note from 3/13/26 documented that the resident had presented with new left leg swelling and redness and had undergone an ultrasound to rule out a blood clot, which was negative, but there was no order from the physician to increase apixaban to 12.5 mg. During an interview, the ADON stated that the nurse who transcribed the order mistakenly changed the apixaban dose and that the nurse who administered the medication did not notice that the new ordered dose would have equaled five tablets instead of one. The ADON further stated that an audit later showed that the 12.5 mg strength was associated with a new order for Aldactone, not apixaban, confirming that the transcription error had occurred in the medication orders for this resident.
Failure to Prevent and Adequately Offload Sacral Pressure Ulcer
Penalty
Summary
Facility staff failed to provide necessary care to prevent the development of a sacral stage 3 pressure ulcer in one cognitively impaired, highly dependent resident. The resident had Alzheimer's disease, heart failure, diabetes, severe impairment in daily decision-making (BIMS score 3/15), and required substantial to maximal assistance for most self-care and mobility tasks. The care plan identified a potential for impaired/compromised skin integrity related to bilateral lower extremity edema and incontinence, with interventions including observing pressure areas for redness, notifying the nurse of any redness, encouraging and assisting with turning and positioning, assisting the resident to bed during the day for pressure relief, and assisting with repositioning as needed. A low-air-loss mattress was not added until late February. Weekly skin assessments initially documented no skin issues on 2/4/26, with barrier cream used on both buttocks as a preventative measure due to incontinence. By 2/11/26, nursing documentation identified moisture-associated skin damage (MASD) on the sacrum, which continued to be documented on 2/18/26. On 2/22/26, nursing documentation described an open wound to the sacrum measuring 2 cm x 2 cm, which was not staged at that time but was cleaned with normal saline and covered. When the wound care physician first evaluated the resident on 2/24/26, the sacral wound was identified as a stage 3 pressure ulcer of pressure etiology, measuring 2.0 cm x 1.5 cm x 0.2 cm, with 100% granulation tissue and moderate serous drainage, and treatment with calcium alginate with honey was ordered. Despite the resident’s high risk for pressure injury and the presence of a sacral pressure ulcer, observations on multiple days showed the resident remaining in a wheelchair for extended periods. On 3/11/26, the resident was observed in a wheelchair in her room at approximately 11:00 AM and again at 3:50 PM. On 3/12/26, the resident was observed in bed at about 9:15 AM with breakfast, then out of bed in a wheelchair at 11:07 AM being taken to the dining room, and again in the wheelchair in her room at approximately 4:30 PM. On 3/18/26 at about 11:00 AM, the resident was again observed sitting in a wheelchair in her room. A CNA reported that the resident was out of bed daily before 11:00 AM because the spouse wanted the resident to have lunch in the dining room. The DON stated that direct care staff had assured her they shifted the resident’s weight when seated in the wheelchair, but there was no indication that the nursing team had educated the responsible party or power of attorney about the need to offload pressure to promote healing and prevent additional pressure ulcers, while the resident was also observed receiving no encouragement or assistance from staff with meals.
Failure to Provide Adequate Supervision During Incontinence Care Resulting in Fall
Penalty
Summary
Facility staff failed to provide adequate assistance and supervision during incontinence care to prevent a fall for one resident. The resident had diagnoses including diabetes, high blood pressure with episodes of orthostatic hypotension, and impaired mobility and self-care related to lumbar spine fusion. An admission MDS with an ARD of 1/6/26 documented a BIMS score of 5/15, indicating severely impaired cognitive abilities for daily decision-making. According to the Rehab Director, the resident was unable to tolerate therapy, was resistant to sitting up on the side of the bed or in a wheelchair, had episodes of low blood pressure, reported feeling ill while sitting up, and would vomit. Prior to the fall on 3/6/26, the resident’s care plan did not include a problem related to resistance to care. On 3/6/26 at 4:30 AM, while a CNA was providing incontinence care, the resident experienced a witnessed fall from the bed to the floor. Nurse’s notes documented that the resident was resisting care, attempted to get out of bed, and slid off the bed to the floor, requiring two staff members to assist her back into bed. The DON later stated that, in this situation, the CNA should have stopped care when the resident became resistant, reminded the resident that she required assistance to get out of bed, ensured the resident was safe, and then reapproached the resident. Family Member #1 reported observing staff working to transfer the resident back to bed after the fall. These findings show that staff did not provide adequate supervision and assistance during incontinence care to prevent the fall.
Failure to Provide Requested Bedside Urinal to Continent Resident
Penalty
Summary
Facility staff failed to provide a requested bedside urinal to a continent/occasionally incontinent resident who had a right intertrochanteric femur fracture, repeated falls, and unsteadiness on their feet. The resident’s admission MDS showed intact cognition (BIMS 15/15), partial/moderate assistance needs for toileting hygiene, and substantial/maximal assistance for bed-to-chair and toilet transfers, with occasional bladder incontinence. The resident’s care plan indicated partial/moderate assistance with toilet use and use of incontinent briefs, and that the resident was able to make self-care decisions daily. On multiple observations over several days, surveyors noted that the resident’s urinal was stored in a bag in the bathroom and not at the bedside, despite the resident’s repeated statements that he had requested, but not received, a bedside urinal. On one observation, when the resident directly asked a CNA for a bedside urinal, the CNA responded that he could not have one at the bedside and must use the call bell to request assistance with using the urinal in the bathroom. In interviews, one CNA stated that bedside urinals were not usually provided due to infection control and that residents were educated to use the call light for assistance, while another CNA stated that if a resident could walk, the urinal would be left in a bag in the bathroom. In contrast, an LPN reported that residents who cannot transfer independently are allowed to have bedside urinals and that staff use them to prevent falls and keep them close so residents do not get up impulsively. The ADON later stated there was no policy regarding bedside urinals and that the resident could have a bedside urinal if able to use it. Throughout the observation period, the resident consistently reported not being provided with the requested bedside urinal.
Altered Pharmacy Label on Benzonatate Medication Card
Penalty
Summary
Facility staff failed to ensure that a medication label remained unaltered from the pharmacy-printed label for a Benzonatate 100 mg capsule card. During a medication administration observation with an LPN, the Benzonatate medication card was noted to have a handwritten "8" written over the previous hourly instructions for administration, which had indicated intervals such as every 4 hours and every 12 hours. Review of the physician’s order summary showed that the original order for Benzonatate 100 mg was 1 capsule by mouth every three hours PRN for cough, which was then changed to every eight hours PRN for cough, and later changed again to 1 capsule by mouth three times a day for cough for 5 days. Pharmacy instructions indicated that the PRN medication on hand should be used. In an interview, the LPN stated that the order had been changed from PRN to scheduled doses and that the pharmacy had instructed staff to use the on-hand medication until a new medication card was received. The facility’s policy titled “Medication and Medication Labels 3.7” stated that if the prescriber’s directions for use change or the label is inaccurate, the nurse may place a “direction change. Change of order-check chart” or similar label on the container, taking care not to cover important label information. Instead of following this policy, the existing pharmacy label on the Benzonatate card was directly altered by handwriting over the original directions. During a subsequent interview, the DON stated that staff nurses are expected to follow the policy. The survey findings regarding the altered medication label were later presented to the facility’s administrative team, who did not offer comments or concerns.
Failure to Maintain Accessible Hospice-Coordinated Plan of Care
Penalty
Summary
The deficiency involves the facility’s failure to have a hospice-coordinated plan of care readily available and integrated into the resident’s record for a hospice-enrolled resident. The resident, admitted after an acute hospital stay, had diagnoses including atrial fibrillation and chronic venous insufficiency, and a significant change MDS showed a BIMS score of 3/15, indicating severely impaired cognitive abilities for daily decision-making. The resident’s care plan, dated 2/4/26, documented admission to hospice services for end-of-life care related to senile degeneration of the brain, with a goal to receive uninterrupted supportive services. Interventions listed included coordinating all of the resident’s needs, communicating changes to hospice, and educating the resident, family, responsible party, and caregivers about changing needs and additional hospice services. Despite this, staff interviews and record review showed that hospice services and coordination were not clearly documented or accessible in the facility. A CNA reported never seeing a hospice aide provide services to the resident and only observing a male nurse visiting approximately twice per week. When interviewed, the DON stated that hospice admission paperwork, the care plan, and visit notes were likely in the resident’s paper chart, but a review of the paper charts revealed no hospice documents. As a result, information about what hospice services would be provided, when and how they would be provided, the communication process, and when or why facility staff should contact hospice was not available in the facility at the time of review. Hospice documents confirming the resident’s hospice admission for senile degeneration of the brain were only produced later, after being faxed to the facility, and the facility leadership acknowledged the non-compliance during the surveyor’s discussion.
Failure to Document Staff COVID-19 Education and Vaccination Status
Penalty
Summary
Facility staff failed to document each staff member’s COVID-19 vaccination and education status as required. During the infection control task, the Human Resource Manager (HRM) reported that there was no documentation for employees with longevity and that only new hires initialed an Orientation Acknowledgement form indicating they were given COVID-19 education. However, the HRM could not produce the actual education materials that were purportedly acknowledged by initials for two of two selected new hires. The HRM later provided the facility’s Infectious Disease COVID-19 Preparedness and Response Plan as the education but was unable to provide documentation that all staff had been offered the COVID-19 vaccine or that their vaccination status had been recorded. These findings were confirmed through staff interviews and review of the available records and policies. No specific residents or their medical histories were mentioned in the report, and the deficiency centered on the facility’s failure to maintain complete and verifiable documentation of staff COVID-19 education and vaccination offerings.
Call Bell Inaccessibility in Resident Room
Penalty
Summary
Surveyors identified a deficiency in ensuring that a working call system was accessible in resident care areas when one resident’s call bell was not within reach while he was in bed. The resident, who had a wedge compression fracture of the fourth lumbar vertebra and was on a subsequent encounter for fracture with routine healing, had been assessed on the 5-day MDS with a BIMS score of 15/15, indicating intact cognitive abilities for daily decision making. On 03/12/26 at approximately 10:45 a.m., the resident was observed lying in bed with the head of the bed elevated to about 45 degrees, while his call bell was on the floor beside the bed and not accessible. During an interview at that time, the resident attempted to drink water and spilled a small to moderate amount on his shirt, then requested something to wipe off the water. When asked to use his call bell for assistance, he stated he could not find it. The resident also reported that he had fallen the previous night, stating that he had pressed the call bell but no one came, and that he had been trying to pull the curtain when he fell onto his left side. Follow-up observations on 03/12/26 showed that at 10:55 a.m. the call bell remained in the same location on the floor, still not accessible to the resident. At 11:14 a.m., CNA #2 entered the room, picked up the call bell from the floor, and placed it at the bedside, stating that she performs resident rounds every 15 minutes. In a final interview on 03/18/26 with the Administrator, DON, ADON, and two corporate consultants, the findings were discussed, and the Administrator stated she had not been made aware of the issue.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fort Belvoir
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenspring Village | 4.1 mi | ★★★★★ | 0 | 0 |
| Westminster At Lake Ridge | 4.9 mi | ★★★★★ | 0 | 0 |
| Belmont Bay Rehabilitation And Healthcare Center | 6.1 mi | ★★★★★ | 1 | 0 |
| Mount Vernon Healthcare Center | 6.4 mi | ★★★★★ | 18 | 0 |
| August Healthcare At Leewood | 7.1 mi | ★★★★★ | 3 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.