VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise of Arlington
2000 North Glebe Road
Arlington, VA 22207
(703) 524-5300

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: May 13, 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 monitoring inspection was initiated on 5/13/21 and concluded on 5/18/21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the census was 37. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three 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 or other prescriber'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 #3's April MAR (medication administration record) was reviewed during the inspection. Resident #3's record contained an order for Baclofen, dated 12/21/20, that called for the resident to receive 5mg by mouth two times per day. The MAR documented that Resident #3' s Baclofen was not administered on 4/17/21 (7 PM administration). The MAR documented that the medication was not administered, as the medication was "pending delivery." Resident #3's record contained a PRN order for Lasix, dated 2/15/21, that called for the resident to receive one 20mg tablet every 24 hours as needed. The MAR states that the medication was given when less than 24 hours elapsed between the administrations on 4/5/21 (11:01 AM) and 4/6/21 (9:58 AM).
Plan of Correction:	Resident #3 did not have any negative outcomes and both medications, Baclofen and Lasix, are available for administration. The Resident Care Director conducted eMAR to medication cart audit to confirm medications were available and timely administered per physician's order. Refresher training with medication care managers and nurse was conducted by the Resident Care Coordinator regarding procedures to follow in order to timely administer medications in accordance with the physician's order. When MCM is unable to locate a medication, the MCM is to check the cart to verify it has not been stored incorrectly, to report to the RCD and notify the physician. If medication aide is unable to locate, the medication will be re-ordered. 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 and timely administered per physician's order. 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 in order 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.