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: June 14, 2022

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 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 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/14/22 (8:30 AM ? 7:35 PM) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-250-C
Description:	Based on record review, the facility failed to ensure that an original criminal record report is included in the staff record. Evidence: The criminal record checks, of new staff members, were observed during the inspection. A criminal record report was not included in the records of Staff #6 and Staff #7, at the time of the inspection.
Plan of Correction:	Criminal record checks for staff members #6 and #7 were completed within 30 days of hire and are in their employee files. BOC or Designee to complete audit of TM files not surveyed by 6/24/2022 to ensure compliance of criminal background checks being completed within 30 days of hire and in staff member files. BOC will complete quarterly audits of new hires to ensure criminal background checks are in staff member files. 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.
Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure that each staff member annually submits the results of a tuberculosis risk assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: The records of Staff #2 and Staff #3 were reviewed during the inspection. The records, for Staff #2 and Staff #3, did not contain a tuberculosis risk assessment that was completed within the past year.
Plan of Correction:	Staff member #2 and #3 Tuberculosis skin tests to be completed on 6/24/2022. BOC or designee to complete audit of TM files not surveyed by 6/24/2022 to ensure compliance of Tuberculosis risk assessment annual completion. BOC or Designee to complete a monthly audit of TM files for TB risk assessments for 3 months. Issues identified will be resolved. 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.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that each direct care staff member maintains current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. Each direct care staff member shall receive certification in first aid within 60 days of employment. Evidence: The record of Staff #5, hired 2/15/22, was reviewed during the inspection. Staff #5's record did not contain first aid certification, at the time of the inspection.
Plan of Correction:	Staff member #5 will be in attendance for first aide training scheduled to take place within 30 days. BOC or Designee to complete audit of TM files not surveyed over the next 3 months to ensure compliance of up-to-date CPR certifications. The community will work with either The American Red Cross and/or independent contractor to ensure TM's without valid CPR certification have completed the training within 60 days. 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.
Standard #:	22VAC40-73-860-I
Description:	Based on record review and observation, the facility failed to keep cleaning supplies and other hazardous materials in a locked area. Evidence: Polident and nail polish remover were observed to be unlocked and unattended in the bathroom of Resident #4, of the memory care unit. Lysol spray cleaner was observed to be unlocked and unattended in a common area of the memory care unit. The record for Resident #4 contained an assessment of serious cognitive impairment, dated 7/12/21, that states that she has a serious cognitive impairment and that she is unable to recognize danger or protect her own safety and welfare.
Plan of Correction:	No negative outcome occurred to resident. Chemical were properly secured and disposed of immediately. A community evaluation sweep of unsecured chemicals was conducted. Team members were re-educated by MC on procedures for safe handling and storage of chemicals. MC or designee checks to confirm that chemicals are properly stored weekly for the next 3 months. Issues Identified will be resolved. For up to 3 months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results of the audits and determine if additional focus or action is warranted. The Executive Director or designee coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.