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

Current Inspector: Marshall G Massenberg (703) 431-4247

Inspection Date: Aug. 15, 2019

Complaint Related: No

Areas Reviewed:
22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:
An unannounced focused monitoring inspection was conducted on 8/15/19 to follow-up on a high-risk violation that was cited on 6/4/19. Medication administration was observed. Medication administration records (MARs) and physician's orders were reviewed. The violation was 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 #: 22VAC40-73-680-D
Description: Based on documentation and interview, the facility failed to ensure that medication is administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence: Resident #1's medication administration record (MAR) was reviewed during the inspection. The MAR stated that Resident #1's Diltiazem was pending delivery on 8/14/19, as the medication was not documented as being given on that date. Facility staff reported that the medication was delivered on 8/13/19, but it wasn't administered on 8/14/19.

Plan of Correction: There were no negative outcomes as result of resident #1 not receiving medication on 8/14/19. The medication was actually located in the community within another medication cart. The medication was placed in the appropriate medication cart in the evening on the same day (8/14/19), the physician and responsible party were notified and the medication was administered per physician order on 8/15/19.

The Wellness Nurse conducted EMAR to medication cart audits on 8/18/19 to confirm that medications were available per physician order and in the appropriate medication cart. Refresher training with medication care managers and nurses was conducted by the Wellness Nurse and Reminiscence Coordinator regarding procedures to follow when unable to locate and administer a medication, including reporting and notification processes, and process to obtain the medication.

The Wellness Nurse or designee will continue to conduct random EMAR to medication cart audits weekly for 3 months to confirm that medications are available per physician order and are stored in the appropriate medication cart.

The Wellness Nurse or designee will continue to conduct weekly audits of the medication administration records for 3 months to confirm medication administration per physician order and corresponding documentation. Issues that may be identified will be addressed and resolved by the Wellness Team.

The Wellness Nurse or designee will present the results of the medication administration record audits and EMAR to medication cart audits to the Quality Assurance and Performance Improvement (QAPI) committee monthly for 3 months.

During and at the end of the 3 months, the Quality Assurance and Performance Improvement (QAPI) Committee will evaluate the results of the medication administration record audits and EMAR to medication cart audits and determine if additional focus or action is warranted.

The Executive Director or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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