Deficiency Records for Belvoir Woods Health Care Center at The Fairfax
Updated as of April 01, 2024
A list of the most recent deficiencies for Belvoir Woods Health Care Center at The Fairfax. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-01-11 | 2023-01-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-11 | 2023-01-31 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-08-24 | 2021-09-24 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-08-24 | 2021-09-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-08-11 | 2021-09-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-11 | 2021-09-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-11 | 2021-09-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-11 | 2021-09-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-11 | 2021-09-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-11 | 2021-09-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-11 | 2021-09-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-05-07 | 2019-08-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-07 | 2019-08-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-07 | 2019-08-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-05-07 | 2019-08-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-05-07 | 2019-08-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-07 | 2019-08-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-07 | 2019-08-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-28 | 2019-05-10 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-03-28 | 2019-05-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-28 | 2019-05-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-03-28 | 2019-05-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-03-28 | 2019-05-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-03-28 | 2019-05-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-28 | 2019-05-10 | N |
