VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Avalon House on Hardwood Lane
1518 Hardwood Lane
Mc lean, VA 22101
(703) 656-8823

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: March 20, 2025

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

Type of inspection: ?Monitoring? Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/20/2025, 09:30 a.m. through 3:00 p.m. 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: 7 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4, plus 1 partial review. Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch and card games Additional Comments/Discussion: none 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 #:	22VAC40-73-1040-B
Description:	Based on observation, the facility failed to ensure that protective devices were on windows in common areas accessible to residents with serious cognitive impairments to prevent the windows from being opened wide enough for a resident to crawl through. Evidence: 1. LI observed a bathroom window on the main level, which faces the front yard, did not have a window stop to prevent the window from opening fully. 2. Photo evidence taken.
Plan of Correction:	Window stop has been placed on the bathroom window to prevent it from opening fully. Facility manager will do spot checks for stops on windows & report any missing stops to administrator and the management team so they may be repaired. Date to Be Corrected 6/5/25
Standard #:	22VAC40-73-40-A
Description:	Based on observation and facility record review, the facility failed to ensure compliance with the facility?s own policies and procedures. Evidence: 1. During a tour of the facility on 03/20/2025, the licensing inspector (LI) observed a small electric icemaker in use in resident 1?s bedroom. 2. The facility?s policy states that residents may not have appliances in their bedrooms. 3. Staff 1 confirmed the LI?s findings during the inspection. 4. Photo evidence taken.
Plan of Correction:	Facility will update appliance policy to reflect that appliances that are approved by the facility only may be used in resident bedrooms. Date to Be Corrected 6/13/25
Standard #:	22VAC40-73-640-A
Description:	Based on staff interview and observation, the facility failed to implement their medication management plan, to include proper disposal of medication. Evidence: 1. During a medication cart audit on 03/20/2025, a box of liquid Lorazepam Intensol was noted in the refrigerated area; however, Resident 4 discharged from the facility on 03/15/2025. 2. Additionally, the facility?s medication management policy states, ?Medication disposal will occur when the following occurs: 4. Client for whom it was prescribed is discharged from the facility?. ?Disposal of controlled substances, schedule II-VI require Registered Nurse and a witness?. 3. Staff 1 and staff 2 confirmed the medication for resident 4 was not properly disposed of upon their discharge, per their medication management plan. 4. Photo evidence taken.
Plan of Correction:	The current medication management policy states the following, ?Medication disposal will occur when the following occurs, ?Client who it was prescribed is discharged from Avalon Homes?. The Medication Management Plan also states, ?These medications will be kept in a locked cabinet at the home until removed. These will be removed on a monthly basis?. The current policy does not state the medication disposal will occur immediately upon discharge. Resident 4 passed away 3/15/25. The Lorazepam is a controlled medication it required both a Registered Nurse and witness to properly dispose of it. Immediately after resident 4 passed away, facility contacted the RN who does oversight at that facility & made arrangements to properly dispose of the medication. They were scheduled to come to the home 3/20/25 in the evening. Until that time, the medication was properly stored in a double lockbox in the refrigerator. During the inspection both staff 1 & 2 had explained this as well as they were in fact in compliance with their medication management plan to the licensing inspector. However, the licensing inspector interpreted the company medication management plan differently. On 3/20/25 the RN and a witness properly disposed of the medication. The current medication management plan will be updated to include a timeframe for medication disposal for any residents who are discharged from the home in order to avoid being misinterpreted in the future.
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to ensure that the interior was maintained in good repair and kept clean and free of rubbish. Evidence: 1. During the facility tour on 03/20/2025, the LI observed the following: a. A white trash bag was loacted in the corner of the dining room. b. The main level bathroom contained a white vanity cabinet with the veneer peeling off the top drawer. 2. At 10:00 a.m., the LI observed resident 4?s bathroom window with a cracked glass pane and a torn window screen. 3. LI observed resident 2?s bedroom carpet with multiple areas of stained and worn spots. 4. LI observed the hard wood floor area leading to the living room. The floor had one plank that was in disrepair and not flush with the other planks. 5. Staff 1 acknowledged the areas of the hardwood floors that were noted to be in need of repair. 6. Photo evidence taken.
Plan of Correction:	a. Resident 1 had placed the trash bag from her bedroom trashcan on the floor in the corner of the dining area for the staff to take to the outside garbage can for her. Staff did take the garbage bag to the trashcan outside during inspection. Staff will request she leave her bedroom garbage bag in her room for staff to pick up as well as staff will check in if it needs to be taken out rather than her placing it outside of her room in the corner of the dining area. Date to Be Corrected 6/5/25 Facility has arranged with a handyman to do the following: a. Replace peeling veneer from the top drawer of the main level vanity. (Date to Be Corrected 6/13/25) b. Replace cracked window pane & torn window screen in resident 4?s bathroom. (Date to Be Corrected 6/20/25) c. Replace worn carpet in resident 2?s room. (Date to Be Corrected 6/13/25) d. The one plank on the wood floor that is in disrepair will be fixed or replaced. (Date to Be Corrected 6/13/25) Facility Manager & administrator will do spot checks and report any item needing to be repaired to the management team.