VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise Assisted Living at Reston Town Center
1778 Fountain Drive
Reston, VA 20190
(703) 956-8930

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: June 9, 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULT 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 6/9/23. At the time of entrance, 62 residents were in care. Meals, medication administration, and activities were observed. Building and grounds were inspected. Records were reviewed. The sample size consisted of eight resident records and four staff records. Violations were 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 #:	22VAC40-73-1100-B
Description:	Based on record review, the facility failed to ensure that a review of continued appropriateness is completed annually for each resident in the special care unit. Evidence: Resident #6's record was reviewed during the inspection. The most recent review of continued appropriateness, included in Resident #6's record, was dated 4/26/22. The review was more than a year old, at the time of the inspection.
Plan of Correction:	The VA REVIEW OF APPROPRIATENESS OF CONTINUED RESIDENCE IN SPECIAL CARE UNIT for Resident #6 was signed by The Executive Director and placed it in the resident?s chart on 6/9/2023. The Executive Director re-educated the neighborhood coordinator on the requirements for REVIEW OF APPROPRIATENESS OF CONTINUED RESIDENCE IN SPECIAL CARE UNIT for all residents living in the Reminiscence neighborhood. The Neighborhood Coordinator (RC) or Designee will audit all the resident?s medical charts in the Reminiscence Neighborhood to verify a review of appropriateness of continued residence in special care unit was completed annually for each resident in the special care unit and is filed in the medical record. The Neighborhood Coordinator (RC) or Designee will verify the VA REVIEW OF APPROPRIATENESS OF CONTINUED RESIDENCE IN SPECIAL CARE UNIT is signed and placed in the medical chart for residents in the Reminiscence Neighborhood at 6 months, and annually thereafter. The results of the audit for the presence of the most up to date form will be presented to the Quality Assurance and Performance Improvement Committee monthly for three months. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur. The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at Quality Assurance/Improvement Meetings and action initiated when/if necessary.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that each direct care staff member maintains current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. Each direct care staff member who does not have current certification in first aid, shall receive certification in first aid within 60 days of employment. Evidence: No documentation was provided, during the inspection, to confirm that Staff #4 (hired 12/2/22) has current first aid certification. Staff #4's record contained documentation of current CPR certification, but not first aid.
Plan of Correction:	Staff #4 will attend First Aid training on June 27, 2023. A copy of the certificate of completion will be filed in Staff #4's personnel record and a copy will be presented to Surveyor. The Business Office Coordinator (BOC) will complete an audit of First Aid training records for all team members to verify that they have a current First Aid certification. Any staff person identified as missing First Aid training will be scheduled for the next available training. New team members will be asked to present current First Aid certification on the first day of hire to the community. A copy of certification will be kept in the appropriate HR file in accordance with regulation. If a new team member is found not to have First Aid certification, they will be enrolled in a certification course for completion within 60 days of employment. The BOC and/or designee will audit team member files monthly to maintain compliance with First Aid regulations. For team members identified, First Aid recertification will be completed within 30 days and required documentation placed in HR file. During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the Executive Director will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices. The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and for addressing and resolving variances that may occur. The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at Quality Assurance/Improvement Meetings and action initiated when/if necessary.