VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise Assisted Living of McLean
8315 Turning Leaf Lane
Mclean, VA 22102
(703) 734-1600

Current Inspector: Alexandra Roberts

Inspection Date: April 1, 2021 and April 5, 2021

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 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.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A inspection was initiated on 4/1/2021 and concluded on 4/5/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 58. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four resident records and four staff records. Criminal record checks and sworn statements of all staff hired since last inspection. Incident reports and other documentation submitted by the facility was reviewed to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review, facility failed to ensure that a person shall have a physical examination and shall contain a statement that specifies whether the individual is considered to be ambulatory or nonambulatory as defined in this chapter. Evidence: Resident #3 was admitted on 11/20/2020 with a physical examination dated 11/06/2020 that documents the resident is "ambulatory" and that the resident used a "hoyer lift for transfer" and does not meet the chapter definition of ambulatory as a condition of a resident who is physically capable of self-preservation by evacuating in response to an emergency to a refuge area.
Plan of Correction:	The Resident Care Director (RCD) contacted resident #3?s primary care physician (PCP). The Executive Director (ED) provided training to the Resident Care Coordinator (RCC) on review of the assessment and physical examinations to verify the ambulatory or non-ambulatory status is accurate per resident. The ED provided training to the RCD on review of the assessment and physical examinations to verify the ambulatory or non-ambulatory status is accurate per resident. The PCP has updated the physical examination to indicate the resident is non-ambulatory. The RCC and RCD conducted an audit of all resident physical examinations and assessment of ambulatory status to verify accuracy. The RCC and/or RCD review the assessment and physical examinations upon receipt, to verify the ambulatory or non-ambulatory status is accurate. The ED conducts monthly audits of physical examinations in comparison to the assessments, to verify the ambulatory or non-ambulatory status is accurate. The Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results of the audits for up to three months following implementation of the plan and determine if additional focus or action is warranted. The ED 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.