VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Avalon House on Woodacre Drive
1505 Woodacre Drive
Mc lean, VA 22101
(301) 656-8823

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: Feb. 28, 2023

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

Technical Assistance:

Documentation was discussed with the provider.

Comments:

An unannounced renewal inspection was conducted on 2/28/23. At the time of entrance, eight resident s were in care. A meal, medication administration, and an activity were observed. Building and grounds were inspected and records were reviewed. The sample size consists of four resident records and three staff records. The violation was discussed and an exit meeting was held. 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. 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 #:	22VAC40-73-620-A
Description:	Based on record review, the facility failed to ensure that each resident with a special diet, receives diet oversight every six months, by a dietitian or nutritionist. Evidence: Resident #3's record was reviewed during the inspection. Resident #3's physical examination report, dated 9/25/18, states that he needs a pureed diet. The most recent dietitian oversight note, included in Resident #3's record, was completed in July 2022. Dietitian documentation indicated that a visit was made to the facility in October 2022, but no documentation was observed to indicate that Resident #3 had diet oversight within the past six months.
Plan of Correction:	Dietitian visited October 2022 and had left documentation in all charts, but had forgotten to leave some in Resident #3's chart. Manager or Administrator will speak with nutritionist while visiting and request documentation be left in all appropriate resident charts. If they do not, manager or administrator will follow-up and request it.