VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Avalon House on Cawdor Court
8103 Cawdor Court
Mclean, VA 22102
(301) 656-8823

Current Inspector: Alexandra Roberts

Inspection Date: March 31, 2022

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. 22VAC40-80 THE LICENSING PROCESS.

Technical Assistance:

Documentation was discussed with the provider.

Comments:

An unannounced monitoring inspection was conducted on 3/31/22. At the time of entrance, eight residents were in care. A meal, medication administration, and an activity were 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. 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-C
Description:	Based on observation and record review, the facility failed to ensure that the comprehensive individualized service plan (ISP) is based upon all of the required information. Evidence: A railing was observed on the bed of Resident #4. Resident #4 was able to demonstrate her independent use of the rail. Resident #4's ISP, dated 3/1/22, did not include information about Resident #4's bed rail.
Plan of Correction:	During the inspection administrator corrected the service plan and added the rail to it. Facility spoke to the physician who will be discontinuing it. When that occurs, the care plan will be corrected accordingly. Administrator will work with the manager doing care plan spot checks in order to ensure the care plans are up to date.
Standard #:	22VAC40-73-620-A
Description:	Based on record review, the facility failed to ensure that there is an oversight, at least every six months of special diets by a dietitian or nutritionist. Evidence: Resident records were reviewed, during the inspection. The last documented dietitian note, in a resident record, was completed in December 2019.
Plan of Correction:	The nutritionist visited the home 9/21/21. They emailed the facility after it was completed to confirm they were there. However, the nutritionist did not leave notes as they should. The inspector was shown the email so they were aware of the visit. On 3/31/22 facility spoke to the nutritionist and reminded them not only do they want a confirmation email of the visit, but notes are also required. Administrator will check for notes after the nutritionist does their visits and ensure they are placed in the proper charts. Facility is working with the nutritionist to schedule a time for their next visit to the facility.
Standard #:	22VAC40-73-680-D
Description:	Based on observation, the facility failed to ensure that medications are administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: The morning medication administration for Resident #4 was observed during the inspection. Resident #4's lactulose was placed into juice for administration, and the bottle was returned to the medication cabinet. Before the medication could be given, the licensing inspector asked about the expiration date of Resident #4's lactulose. The lactulose bottle stated that the medication should not be used after 12/31/21. The morning medication administration for Resident #5 was observed during the inspection. Resident #5's medications were administered after she ate breakfast. During the medication administration, Resident #5 received Omeprazole, Linzess, and Levothyroxine. The pill bottles for the Omeprazole, Linzess, and Levothyroxine included instructions about taking the medications before meals.
Plan of Correction:	RN will do a re-training with the medication technician about expired medications, administering as directed by the prescribing physician. RN will do spot checks to ensure medications are not expired and being administered as prescribed. For resident #5 the doctor's orders did not specify the medications should be taken before meals. However, the inspector pointed out the manufacturer does recommend these medications are taken before meals. Facility will work with facility to update orders as well as have the RN do a training about medications in which the manufacturer suggests taking medications before meals.
Standard #:	22VAC40-73-860-I
Description:	Based on observation, the facility failed to ensure that cleaning supplies are kept in a locked area. Evidence: Disinfectant spray was observed in the bathroom cabinet and in the hallway. The can and bottles of disinfectant spray were unlocked and unattended.
Plan of Correction:	Administrator/Management retrained staff on the importance of locking up cleaning supplies. Manager will do daily spot checks. Administrator will do weekly spot checks.