VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise at Countryside
45800 Jona Drive
Sterling, VA 20165
(703) 430-0681

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: Aug. 3, 2021 and Aug. 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 32.1 Reported by persons other than physicians 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:

A renewal inspection was initiated on 8/3/2021 and concluded on 8/5/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 24. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed three resident records, three staff records, annual health and fire inspections, dietary and healthcare oversight reports, staff work schedule, monthly activities and menus submitted by the facility to ensure documentation was complete. Criminal Background Checks of all staff hired since the previous inspection conducted on 5/21/2021 were reviewed. The inspector conducted the on-site portion of the inspection on 8/4/2021. An exit interview was conducted with the administrator and resident care coordinator on 8/5/2021 where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issue to the facility. 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 standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based upon a review of records and interview, the facility failed to ensure that medications shall be administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlined in the current registered mediation aide curriculum approved by the Virginia Board of Nursing. Evidence: Resident #1 has a physician?s order to receive 5mg of Oxycodone twice a day. On 7/18/2021 the Medication Administration Record (MAR) indicated that Resident #1 was administered the regularly scheduled dosage of Oxycodone at approximately 21:00 (9 pm), however, this dosage is not recorded on the Controlled Medication Utilization Record as being administered. According to the Controlled Medication Utilization Record, after the administration of the 9 am dosage of Oxycodone on 7/18/2021 at approximately 8 am, there were 13 pills remaining. The next date listed on the Controlled Medication Utilization Report is 7/19/2021 at 9:00am, indicating that one tablet of Oxycodone was administered at approximately 9 am and there were 12 remaining pills. The MAR for 8/2/2021 indicates that Resident #1 was administered at approximately 9 am, the prescribed order of 5mg of Oxycodone, however, this dosage is not recorded on the Controlled Medication Utilization Record as being administered. The Controlled Medication Utilization Record indicates that Resident #1 was administered the dosage of Oxycodone on 8/1/2021 at approximately 21:00 (9pm) leaving 40 pills remaining. The next date listed on the Controlled Medication Utilization Record is 8/2/2021 at approximately 21:00, indicating that one tablet of Oxycodone was administered and there were 39 pills remaining. Resident #3 has a physician?s order to receive 0.5 mg of Clonazapam every 24 hours. According to the MAR, Resident #3 was administered the medication twice on 7/5/2021 at approximately 12:31 am and 10:35 pm.
Plan of Correction:	Resident #1 experienced no negative outcomes as a result of missing one dose of a prescribed order of Oxycodone 5mg twice a day not being administered on 7/18/2021 and 8/2/2021 as prescribed. Resident #3 experienced no negative outcomes as a result of receiving Clonazepam 0.5mg twice on 7/5/2021 when the order states Clonazepam 0.5mg once every 24 hours as needed. The Resident Care Director (RCD) conducted an audit on the Controlled Medication Utilization Records against the Electronic Medication Administration Records (EMARS) to ensure medication administration was correctly documented. The RCD and Wellness Nurse conducted medication pass observations to confirm medications are administered in accordance with physician orders. No additional concerns were identified. Medication Care Managers (MCMs) were re-educated by the RCD regarding the process for correct documentation regarding controlled substance. Education modules pertaining to PRN (as needed) medication management, medication administration, avoiding common errors, medication pass process, and documenting in the EMAR were assigned to all MCMs and will be mandatory to complete by 8/31/2021. The RCD or Wellness Nurse conducts weekly medication pass observations for 1 month and then monthly for 2 months to confirm that medications are being administered in accordance with physician orders. The RCD or Wellness Nurse audits Controlled Medication Utilization Records against the EMAR weekly for 1 month and then monthly for 2 months to confirm medications are being documented in accordance with physician's orders. The RCD or wellness designee will present the results of the audits to the Qualify Assurance and Performance Improvement (QAPI) Committee monthly for three months. During and at the end of the 3 months, the QAPI Committee will evaluate the results of the resident record 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.