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: March 2, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced inspection was conducted on 3/2/22, in response to a complaint that was received by the licensing office on 2/24/22. One resident record was reviewed. The allegations were determined to be valid, as a preponderance of evidence supported the allegations. The 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, contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that individualized service plans are reviewed and updated for a significant change of a resident's condition. Evidence: Resident #1 was admitted to the facility on 1/7/22. Resident #1's uniform assessment instrument (UAI), dated 1/7/22, states that the resident does not need assistance for eating/feeding. Resident #1's ISP, dated 1/7/22, states that staff will prepare and serve the resident's meals and snacks. The ISP also states that the resident's liquids would be thickened to be honey thick and that staff will follow for meals and snacks. Hospital documentation indicates that Resident #1 was taken to the hospital on 1/23/22, and that he returned to the facility on 1/26/22. Hospital discharge instructions, dated 1/26/22, recommends "continuing comfort feeds with aspiration precautions. Please keep the head of the bed elevated greater than 45 degrees with close supervision while eating or drinking." Resident #1's record contains orders, dated 1/27/22, that state: Patient may receive PO fluids, thickened to honey texture given by spoon PRN; 2) He may also receive PO soft pureed foods by small spoonfuls PRN SLOWLY; 3) Aspiration precautions. Resident #1's ISP was not updated to include aspiration precautions and his need to be spoon fed by staff.
Plan of Correction:	Facility has arranged for a trainer who has been approved by the Virginia Board of Long-Term Care Administrators to retrain staff and Administrators about updating documentation on the ISP. Administrator will check the ISPs weekly and make changes needed. The RN will check them monthly.
Standard #:	22VAC40-73-470-C
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that services are provided to prevent clinically avoidable complications, including: Pressure ulcer development or worsening of an ulcer. Evidence: Resident #1's record was reviewed during the inspection. A hospice note, dated 1/27/22, states that Resident #1 has a stage 1 ulcer to his coccyx. The record also contains an order, dated 1/28/22, that calls for Calmoseptine to be applied topically to the coccyx area, every time incontinence care is provided. A hospice note, dated 1/28/22, states that ALF staff are aware to turn reposition Resident #1 every two hours. Resident #1's ISP, dated 1/7/22, states that he is incontinent of bowel and bladder, and that staff will use pericare at changes. Resident #1's facility notes and medication administration record (MAR) were also reviewed during the inspection. There was no information in the resident record that documents the turning/repositioning of Resident #1 every two hours, or the application of Calmoseptine after incontinence episodes.
Plan of Correction:	Facility has arranged for a trainer who has been approved by the Virginia Board of Long-Term Care Administrators to retrain staff and Administrators about updating documentation on the ISP and MAR. Administrator and Med tech will check them weekly and make changes as needed. RN will check them monthly.