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: July 30, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A non-mandated self-report inspection was initiated on 7/30/21 and concluded on 9/2/21. A self-reported incident was received by the department regarding allegations in the area of: Resident Care and Related Services. The licensing inspector conducted on-site observations at the facility on 7/30/21 and 9/2/21. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-460-D
Description:	Based on record review and interview, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs. Evidence: On 7/10/21, Resident #1 was observed outside of the facility by a staff member that was returning from a lunch break. Staff #1 reported that Resident #1 was observed near the gate of the facility's secure outdoor area. Resident #1's UAI (Uniform Assessment Instrument), dated 3/16/21, indicates that the resident has a history of wandering and refusing care. Resident #1's ISP (Individualized Service Plan), dated 4/5/21, states that the resident is an exit seeker, that can be combative and aggressive at redirection. The record for Resident #1 includes an assessment of serious cognitive impairment form that states that he has a serious cognitive impairment, and that he is unable to recognize danger or protect his own safety and welfare.
Plan of Correction:	Resident #1 was immediately located right outside exit doors and returned to the secured unit by a staff person. The resident was assessed and found to have no injury or other clinical concerns. An immediate head count of all residents was conducted by the Lead Care Manager to verify that all residents were present. An inspection of all exit doors was performed by Care Managers. The Maintenance Coordinator secured all exit doors from the secured neighborhood and verified the magnetic locks were operational. An audit of all doors is performed by the Lead Care Manager at the start of each shift to verify the exit doors are operational, for the secured neighborhood. Shift audit sheets will be turned in by the Lead Care Managers to Reminiscence Coordinator (RC) or designee at the end of each shift. The RC or designee will review audits for competition, and follow up with responsible Lead Care Manager for any deficits. The Executive Director conducted in person Team Member education on "Responding to Exit-Seeking Behaviors" and "Preventing Elopement" The Maintenance Coordinator or designees continue to conduct monthly elopement drills. The Maintenance Coordinator or designee performs an audit of all doors following any fire drill, during which magnetic locking mechanism becomes disabled to allow for egress in the event of an emergency. The results of the audits will be presented by the Reminiscence Coordinator or designee at QAPI (Quality Assurance and Performance Improvement) for 3 months. During and at the end of the 3 months, the QAPI Committee will evaluate the results of the exit door 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.