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: June 4, 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 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 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: 06/04/2024, 09:00-12:30. 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 Number of resident records reviewed: 3 Number of staff records reviewed: 4 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Toured the facility, observed medication administration, and checked the medication cart for prescribed medications. LI also observed residents participating in activity programs and eating breakfast and lunch. 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 #:	22VAC40-73-50-A
Description:	Based on facility record review and staff interview, the facility failed to ensure the disclosure statement was on the form developed by the Virginia Department of Social Services (VDSS). Evidence: 1. Staff 2 provided the Disclosure Statement to the licensing inspector. 2. The Disclosure statement form was edited. The footers on all pages and the formatting for the entire document had been adjusted. 3. Staff 2 confirmed that they had modified the original department form.
Plan of Correction:	Facility was using an outdated Disclosure Statement. Administrator sent a new Disclosure Statement that meets the current requirements to all families in the home for review, initials, and signature & requested they be returned to the office. A copy will be filed in the resident charts upon receipt. The correct Disclosure Statement has been added to the admission packet all incoming residents will receive by the Administrator.
Standard #:	22VAC40-73-410-A
Description:	Based on record review, the facility's resident orientation form was not signed by the resident. Evidence: The resident orientation information form was not signed by the resident 1.
Plan of Correction:	An orientation had been given to Resident 1 upon admission. Due to their diagnosis, they were unable to sign their name. Their POA had signed it, however. Going forward after the orientation is completed, if a resident is unable to sign their name, it will be documented as such on the form that it was completed and the resident is not able to sign their name. Any current orientation form in which a resident was unable to sign their name after completion has been updated to state as such.
Standard #:	22VAC40-73-620-B
Description:	Based on record review and staff interview, the facility?s dietary oversight form did not contain a dietary certification statement. Evidence: Staff 1 provided a record of on-site dietary oversight dated 4/14/2024, which did not include certification that the requirements of the regulations were met.
Plan of Correction:	The dietician has written an addendum to her written chart notes from the visit stating they have certified the regulations were met during her last visit. The addendum has been added to the dietician notes in the resident charts. The dietician will add the certification statement going forward after she completes her visit and finds the regulation has been met.