VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Avalon House on Laburnum Street
1453 Laburnum Street
Mc lean, VA 22101
(301) 656-8823

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: Aug. 21, 2024

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 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 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:

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/20/2024 and 08/21/2024, 9:30am-2:45pm and 9:30 am-5:44pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 8 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast, lunch, activities. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at 703-397-3017, or by email at Jacquelyn.Kabiri@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-C-2
Description:	Based on direct observation and audit of the medication cabinet, the facility failed to follow its Infection control policy. Evidence: 1. The facility's infection control policy states that all contaminated sharps shall be discarded as soon as feasible in sharps containers located close to the point of use as feasible in each work area. 2. LI observed three used syringes in cabinet drawer three, in the medication cabinet not in a sharps container. 3. Photos taken as evidence.
Plan of Correction:	The syringes in drawer three had not been used. However, the plastic bag they came in had torn off. Therefore, they should have been discarded. They were discarded during the inspection per the infection control policy. RN will ensure staff are retrained in infection control as well as the facility infection control policy and do random audits to ensure it is being followed
Standard #:	22VAC40-73-210-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure staff attend at least 4 hours of annual training on topics related to resident mental impairments. Evidence: 1. Upon record review Residents 3, 4, and 5 have a mental health diagnosis. 2. Staff record reviewed, Staff 2 date of hire 11/12/2008, and Staff 4 date of hire 07/19/2021, do not have four hours of specific training in mental health annually. 3. Staff 1 confirmed during an interview on 08/21/2024, that Staff trainings were not specific to 4 hours in mental health annually. annually.
Plan of Correction:	While employees have attended/completed trainings about residents with cognitive impairments, wandering, agitation, aggression, & common emotions/behaviors expressed by assisted living residents which can be related to resident?s mental impairments, staff had not taken training specific to them. Staff has since attended trainings that are at least 4 hours that are specifically for mental impairments. RN will ensure they attend at least 4 hours of mental health trainings if a resident residing in the home has a mental health diagnosis.
Standard #:	22VAC40-73-260-C
Description:	Based on observation of facility postings, the facility failed to post a listing of all staff who have current certification in first aid or CPR so that the information is readily available to all staff at all times. Evidence: 1. The facility did not have a list posted of staff certified in first aid/CPR. 2. On 08/21/2024, staff 1 and staff 2 acknowledged a listing of all staff who have current certification in first aid or CPR is not posted in the facility.
Plan of Correction:	All staff in the home have been trained in CPR & First Aid. Their certificates are filed in their staff records. However, it was not posted on the bulletin board. Administrator and manager have posted this on the bulletin board and will ensure it is maintained as well as current.
Standard #:	22VAC40-73-290-A
Description:	Based on direct observation, review of facility documentation, and staff interview, the facility failed to maintain a written work schedule that includes the names and job classifications of all staff working each shift with an indication of whomever is in charge at any given time. Evidence: 1. The facility submitted a staff information sheet with each staff member's name. 2. The name of staff 2 is listed on a white standard-sized paper 8x11.5, posted on the whiteboard area, with the heading "Manager on Duty" but no schedule, date, or time listed. 3. The name of staff 3 is listed on a white standard-sized paper 8x11.5, posted on the whiteboard area, with the heading "Manager on Duty" but no schedule, date, or time listed. 4. Staff 1 confirmed on 08/21/2024, the facility does not have a written shift schedule listing name, position, date, time, and hours working.
Plan of Correction:	During inspection facility had a work schedule hanging which included the dates of work for each employee. Facility also had a sign hanging which shared which staff was the manager on duty during that time. Their name was on the hanging scheduled mentioned as well. However neither included the shift. A work schedule that will include the shift for the direct care staff as well as the manager on duty shall be created, maintained and posted in the home to replace the ones hanging during inspection. Manager will maintain the schedule. Manager & Administrator will do spot checks to ensure it is being done properly & maintained.
Standard #:	22VAC40-73-300-B
Description:	Based on document review, resident record review, and staff interview, the facility failed to ensure a method of written communication shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. Evidence: 1. LI requested to view the staff communication log for the facility. 2. Staff 1 and staff 2 confirmed during an interview with LI on 08/21/2024, that the facility does not use a written communication log for staff but verbally communicates information.
Plan of Correction:	A communication log is now being used in the home. Manager will ensure it is readily available & updated in order to keep staff informed of significant happenings or problems experienced by residents including complaints and incidents or injuries related to mental or physical conditions.
Standard #:	22VAC40-73-350-C
Description:	Based on staff interview, the facility failed to ensure an annual review of information on the sex offender registry, including how to obtain such information and to ensure that written acknowledgment of having been so informed was provided to the resident or his legal representative and shall be maintained in the resident's record. Evidence: 1. LI (Licensing Inspector) requested documentation for Resident 1,2,3,4,5,6, and 7 of resident acknowledgment of receipt. 2. Staff 1 acknowledged during an interview with the LI (Licensing inspector) that the annual review and documentation of informing residents of the sex offender registry was not completed to meet the (VDSS) Virginia Department of Social Service standards and was not on file for any of the requested records.
Plan of Correction:	Administrator had been sending out the sex offender registry information in the admission paperwork as well as annually to all families. However, it was missing one item which meant the letters were not in compliance with VDSS regulations. The information has been updated so that it does meet VDSS licensing regulations. Copies have been furnished to the responsible parties for review & signature. The corrected information shall be sent out annually for review.
Standard #:	22VAC40-73-550-A
Description:	Based on record review, observations and interviews, the facility failed to ensure residents are encouraged and informed of appropriate means as necessary to exercise his rights as a Resident and a citizen throughout the period of his stay at the facility. Evidence: 1. LI observed on 08/21/2024, interactions between staff 4, staff 5, and Resident 1. 2. Resident 1 repeatedly asked to have cigarettes to smoke. 3. Staff 4 and Staff 5 told Resident 1 they can only have 3 cigarettes a day. 4. LI interviewed Staff 2, Staff 4, and Staff 5, regarding the Resident's request and their remarks to the Resident on their daily cigarette limit. 5. Staff 2, 4, and 5, claimed the spouse of Resident 1, put the daily limit to 3 cigarettes a day. 6. Resident 1's records did not indicate on ISP (Individualized service plan) of any cigarette limit for the Resident. 7. Resident 1's records have no physician order for a smoking or daily cigarette limit. 8. The facility's smoking policy has no mention of a daily limit on cigarettes or smoking times for Residents.
Plan of Correction:	Resident 1 is a smoker. Their responsible party as well as their primary had verbally communicated with the facility upon move in due to health issues smoking can cause; they requested the resident smoke no more than 3 cigarettes per day. Facility had been following those requests. Administrator and Manager consulted with the responsible party, resident and the resident?s primary NP after the inspection. The primary NP wrote an order stating the resident can smoke up to 3 cigarettes per day. It has been documented on the ISP by the administrator.
Standard #:	22VAC40-73-640-A
Description:	Based on observation of the facility's medication storage cabinets and document review, the facility failed to implement their medication management plan. Evidence: 1. The facility's medication management plan is to have the medication technician on duty to check medications daily to remove any outdated, damaged, or contaminated medications. 2. The facility's medication storage cabinets contained the following expired medications: a. Resident 7's Albuterol 0.5-2.5 vials for nebulizer, expired 07/28/2024. b. Leader Antacid liquid, 12fl oz, expired 7/2024 (Bottle has no label with Resident's name). c. Mylanta max strength antacid 12 fl oz, expired 08/2018, (Bottle has no label with Resident's name). 3. Resident 7 was no longer in the facility since 2023, however, their medication remained in the medication cabinet. 4. Photos taken as evidence.
Plan of Correction:	The medication technician removed expired medications from the locked medication cabinet. RN will give a re-training of the Medication Management Plan to medication technicians
Standard #:	22VAC40-73-660-A-2
Description:	Based on the medication cabinet audit, the facility failed to store schedule II drugs and any other drugs subject to abuse in a separate locked storage compartment, e.g., a locked cabinet within a locked storage area or a locked container within the cabinet. Evidence: 1. Resident 4's prescription for Lorazepam,2mg, was not locked in a container within the medication cabinet. 2. The prescription is noted to be a drug subject to abuse. 3. Photos taken as evidence.
Plan of Correction:	Schedule II medications shall be kept double locked. This was corrected the evening of the inspection. RN will do random audits to ensure schedule II medications are being stored properly.
Standard #:	22VAC40-73-680-B
Description:	Based on the audit of the medication cabinet, the facility failed to ensure single-use and dedicated medical supplies and equipment shall be appropriately labeled and stored. Evidence: 1. One plastic bag containing four syringes with no prescription label. 2. Photos taken as evidence.
Plan of Correction:	The syringes in the bag were extra syringes and not for a specific resident. If syringes are for a specific resident the medication technician shall ensure they are labeled. If they are not for a specific resident and are extra, they will be labeled as extra. Medication Technician and RN shall do monthly audits to ensure this is occurring.
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to ensure that the interior and exterior of the building was maintained in good repair and kept clean and free of rubbish. Evidence: 1. The carpet in Resident 6's bedroom was stained and had a dingy appearance. 2. The exterior front handrail post cover was broken with sharp corners. 3. Photos taken as evidence.
Plan of Correction:	A new carpet has been installed in Resident 6?s bedroom. The handrail post cover has been replaced. Manager will report any interior & exterior areas to the entrance of the facility physical plant issues such as carpet repair to the administrator, maintenance, or upper management so that the facility shall be maintained in good repair, and kept clean.
Standard #:	22VAC40-73-930-D
Description:	Based on staff interview, the facility failed to ensure that documentation of staff rounds was completed that included the name of the resident, date and time of rounds, and the staff member who made the rounds for residents who were unable to use the signaling device. Evidence: 1. During interviews with Staff 1 and 2, with LI on 08/21/2024, along with review of Residents records, Residents 1 and 2 were not able to use a call bell signaling device. 2. The facility does not have a rounding log to document Resident monitoring. 3. Staff 1 and Staff 2 confirm there is no rounding log in use.
Plan of Correction:	A rounding log shall be used & maintained for residents who cannot use their call buttons. Manager shall maintain the log. Manager & Administrator will do spot checks to ensure it is being done properly & maintained
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review and staff interview, the facility failed to ensure that a criminal history record report was obtained on or prior to the 30th day of employment for each employee. Evidence: 1. The record for staff 3, date of hire 06/21/2024, did not contain documentation that a criminal history record report was obtained within the first 30 days of employment. 2. Hire date as 01/31/2006, however, staff 3 left and returned to work on 06/21/2024. 3. Was last conducted on 10/17/2017. 4. The record dated 10/17/2017 was in the staff file. 5. Staff 3 left employment on 09/19/2023 for personal reasons and returned on 06/21/2024.
Plan of Correction:	A new criminal history record report has been obtained for Staff #3. Should a staff person take a leave of absence going forward, a new criminal history record report shall be obtained upon their return.