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: Nov. 16, 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 63.2 GENERAL PROVISIONS 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

Comments:

An unannounced renewal inspection was conducted on 11/16/22 (8:00 AM ? noon). At the time of entrance, eight residents were in care. Meals, medication administration, and an activity were observed. Building and grounds were inspected. Facility documents 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 licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-290-B
Description:	Based on observation, the facility failed to implement a procedure for posting the name of the current on-site person in charge. Evidence: Upon the licensing inspector?s arrival at the facility, Staff #1 was listed as the manager on duty. Staff #1 was not present at the facility, when the inspection began.
Plan of Correction:	Manager on Duty/Person in charge signage will be changed as the person in charge and on duty changes. Administrator will check the sign weekly to ensure it reflects the person in charge and on duty. The signs have been updated and changed to reflect who is on duty and in charge currently.
Standard #:	22VAC40-73-610-D
Description:	Based on observation and documentation, the facility failed to ensure that each diet prescribed by a physician is prepared and served according to the physician?s or other prescriber?s orders. Evidence Resident #2 was observed eating cold cereal with milk. Resident #2?s physical, dated 7/25/22, states that she needs a mechanical soft diet.
Plan of Correction:	Facility works with a licensed nutritionist whose degree specializes in elderly nutrition. The nutrition team shared with staff & administrator it is alright to serve breakfast cereal with a mechanical soft diet if it is softened with warm milk prior to serving it. The staff had softened the breakfast cereal with warm milk by pouring it over the entire bowl and waiting a few minutes before serving it to Resident #2. That is how it was served to Resident #2. Administrator did present the licensing inspector with an email stating this was alright and would be considered mechanical soft for this particular resident less than 24 hours after the inspection and prior to receiving the violation notice. Licensing inspector felt this was still a violation. Facility will work with the nutrition team and have someone from their team or an RN the company consults with to re-train staff about mechanical soft diets.
Standard #:	22VAC40-73-660-B
Description:	Based on observation and documentation, the facility failed to limit medication storage to an out-of-sight place in the rooms of residents whose UAIs have indicated that the residents are capable of self-administering their medication. Evidence: Valsartan and antacid tablets were observed unattended on a table in the room of Resident #1. Resident #1?s Uniform Assessment Instrument (UAI), dated 10/25/22, states that the resident needs her medication administered/monitored by facility staff.
Plan of Correction:	At this time, residents were eating breakfast in the kitchen. A staff member had just arrived home from the emergency room for themselves with their own medication. They were in the bedroom of Resident #1. Another staff person called Staff #2 out of the bedroom to answer some questions in regard to the inspection putting down their medications in the bedroom leaving them unlocked. They were not the medication of Resident #1. RN will re-train staff about keeping medications locked up and safe medication storage.
Standard #:	22VAC40-73-680-D
Description:	Based on observation and record review, the facility failed to ensure that medications are administered in accordance with the physician?s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Medication administration was observed for Resident #3 during the inspection. Resident #3?s record contained an order (dated 8/26/22) for the resident to receive Acetaminophen twice per day. Resident #3?s Acetaminophen was not administered during the initial medication pass and that order was not included in Resident #3?s November medication administration record (MAR).
Plan of Correction:	RN will re-train medication technician about MARS documentation, and medication passes. Administrator and RN will check MARS weekly to ensure medications are documented properly. It has been fixed on the MAR just after the inspection by the on duty medication technician.