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: April 28, 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. 22VAC40-80 THE LICENSING PROCESS.

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 renewal inspection was initiated on 4/28/21 and completed on 4/30/21. The administrator's designee was contacted by telephone to initiate the inspection. The administrator's designee reported that the census was 57. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four resident records, four staff records, medication administration records, local fire and health inspections, and other documentation submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility. 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 record review, the facility failed to ensure that medications are 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 #4's March MAR (medication administration record) was reviewed during the inspection. Resident #4's record contained an order for Gabapentin, dated 2/26/21, that called for the resident to receive a 100mg capsule three times per day. The MAR documented that Resident #4's Gabapentin was not administered on 3/26 (8 PM administration), 3/27 (8 PM administration), 3/28 (all administrations), and 3/29 (all administrations). Resident #4's progress notes and MAR indicated that the medication was not administred on those dates, because the medication was not present at the facility.
Plan of Correction:	There were no negative outcomes as a result of resident #4 not receiving medication, gabapentin. The Wellness Nurse ordered the medication immediately. The medication has been received, is available in the medication cart, and is being administered per physicians' orders. The Resident Care Director conducted EMAR to medication cart audits to confirm medications were available per physician order. Refresher training with medication care managers and nurses was conducted by the Resident Care Coordinator regarding procedures to follow when unable to administer a medication and process to obtain the medication. The Resident Care Director or designee will continue to conduct EMAR to medication cart audits weekly for 3 months to confirm that medications are available per physician order. The Resident Care Director or designee will present the results of the medication cart audits to the Quality Assurance and Performance Improvement (QAPI) Committee for 3 months. During and at the end of the 3 months the Quality Assurance and Improvement Committee will evaluate the results of the EMAR to medication cart audits and determine if additional focus or action is warranted. The ED 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.