VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Avalon House on Gelston Circle
1011 Gelston Circle
Mc lean, VA 22102
(301) 656-8823

Current Inspector: Alexandra Roberts

Inspection Date: Dec. 30, 2019

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 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.

Comments:

An unannounced renewal inspection was conducted on 12/30/19 (7:30 AM - 12:35 PM). At the time of entrance, eight residents were in care. A meal, medication administration, and an activity was observed. Building and grounds were inspected and records were reviewed. The sample size consisted of four resident records and three 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 #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure that each resident's physical examination contains all of the required information. Evidence: The physical examination for Resident #2, dated 3/12/19, was observed during the inspection. The physical examination form stated that the resident was allergic to: iodine, macrobid, sulfa and antibiotics. The form did not list Resident #2's allergic reactions. The physical examination for Resident #3, dated 7/18/19, was observed during the inspection. The physical examination form stated that the resident was allergic to shellfish. The form did not list Resident #3's allergic reaction to shellfish.
Plan of Correction:	Prior to admission upon receipt of medical forms administrator will ensure the allergic reaction is written on the physical exam. If it is not, they will contact the physician to add the reaction. This will be completed for every move in beginning 1/18/20.
Standard #:	22VAC40-73-680-I
Description:	Based on documentation, the facility failed to ensure that the medication administration record (MAR) contained all of the required information. Evidence: The medication administration record (MAR), for Resident #1, was reviewed during the inspection. The MAR did not contain a reason or diagnosis for Resident #1's: Colestipol, Atorvastatin, or Synthroid.
Plan of Correction:	Corrected during inspection. RN will review MARs monthly to ensure reason\diagnosis is written on the MAR.