VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Avalon House in McLean
1503 Oakview Drive
Mc lean, VA 22101
(301) 656-8823

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: May 11, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES2VAC40-73 GENERAL PROVISIONS 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

Comments:

An unannounced renewal inspection was conducted on 5/11/22. At the time of entrance, two residents were in care. Building and grounds were inspected. An activity was observed. Medication and records were reviewed. The sample size consisted of two resident records and two staff records. 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, please contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-560-E
Description:	Based on observation, the facility failed to ensure that resident records are kept in a locked area. Evidence: Shortly after 9 AM, a cabinet was left unlocked and unattended. The cabinet contained resident records.
Plan of Correction:	At the time of the inspection, facility had a census of 2 residents. The medication & resident record cabinet is located in the dining room. The two residents were sitting in the living room being attended to by 2 caregivers making it a 1:1 staff to resident ratio. The Medication Technician was also in the living room with the two residents and two other caregivers where the living room connects to the dining room. The Medication Technician was around four feet from the medication & resident record cabinet, which was closed, and was in the standing in pathway that would have been taken from the living room to the dining room by either of the two residents should they have attempted to open the medication cabinet. Facility RN will retrain the Medication Technician to ensure the cabinet is kept locked and not left unattended. Administrator and RN will do spots checks.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation, the facility failed to ensure that the medication storage area remains locked. Evidence: Shortly after 9 AM, a cabinet was left unlocked and unattended. The cabinet contained resident medication.
Plan of Correction:	At the time of the inspection, facility had a census of 2 residents. The medication & resident record cabinet is located in the dining room. The two residents were sitting in the living room being attended to by 2 caregivers making it a 1:1 staff to resident ratio. The Medication Technician was also in the living room with the two residents and two other caregivers where the living room connects to the dining room. The Medication Technician was around four feet from the medication & resident record cabinet, which was closed, and was in the standing in pathway that would have been taken from the living room to the dining room by either of the two residents should they have attempted to open the medication cabinet. Facility RN will retrain the Medication Technician to ensure the cabinet is kept locked and not left unattended. Administrator and RN will do spots checks.
Standard #:	22VAC40-73-680-I
Description:	Based on record review, the facility failed to ensure that the medication administration record (MAR) includes: the time that each medication is given. Evidence: The April and May MARs, for Resident #1, did not include the time that each medication was scheduled to be given. Resident #1?s MARs included AM or PM for each medication, but no times were listed to indicate when the resident?s medications would be administered.
Plan of Correction:	RN that works with facility will retrain Medication Technician in regard to MAR documentation and administration times. RN will check the MARS monthly.