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: Feb. 9, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUNDS

Comments:

An unannounced focused monitoring inspection was conducted on 2/9/23, to follow-up on high-risk violations that were cited on 11/16/22. Medication administration was observed, physician's orders were reviewed, and building and grounds were inspected. 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 #:	22VAC40-73-680-D
Description:	Based on observation and record review, 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: Resident #1 was administered one 500mg tablet of Acetaminophen, during the observed medication pass. Resident #1's medication administration record (MAR) called for the resident to receive one 500mg tablet of Acetaminophen, and the date prescribed was listed as 6/6/22. The most recent Acetaminophen order, included in Resident #1's record, was signed 11/3/22 and called for the resident to receive two 500mg tablets of Acetaminophen during the morning medication pass.
Plan of Correction:	RN will retrain the medication technicians at that home about MARs documentation and medication passes. Administrator and RN will check orders and MARs weekly to ensure they are received and documented properly.
Standard #:	22VAC40-73-860-I
Description:	Based on observation, the facility failed to ensure that cleaning supplies and other hazardous materials are stored in a locked area. Evidence: Liquid bleach was observed to be unlocked and unattended on the kitchen counter. Disinfectant spray was observed to be unlocked and unattended in a cabinet, under the kitchen sink.
Plan of Correction:	Administrators and management have been doing ongoing spot checks and training in regard to keeping chemicals locked up. Staff will get another training and spot checks will continue. Administrator had a nice conversation discussing this and asked for other ideas during exit interview with the inspector.