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: June 3, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES2VAC40-73 GENERAL PROVISIONS 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 ADULT 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:

An unannounced monitoring inspection was conducted on 6/3/22. At the time of entrance, 60 residents were in care. Meals, medication administration, and activities were observed. Building and grounds were inspected. Records were reviewed. The sample size consisted of four staff records and eight resident records. The violations were discussed and an exit meeting was held. 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 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 #:	22VAC40-73-660-B
Description:	Based on observation and documentation, the facility failed to limit medication storage to an out-of-sight place in the rooms of residents whose UAIs have indicated that the residents are capable of self-administering their medication. Evidence: Medication administration for Resident #1 was observed during the inspection. Two bottles of Tylenol were observed on Resident #1?s shelf. Resident #1?s Uniform Assessment Instrument (UAI), dated 2/1/22, states that the resident needs her medication administered/monitored by professional nursing staff.
Plan of Correction:	Resident experienced no negative outcomes from having OTC Tylenol in her room. Team member who observed Tylenol in the room was re-educated on the policy for medications at the bedside on the day of the inspection by the RCD. All Med Care Managers and Care Managers will be re-educated by the Resident Care Director (RCD) or designee on the policy for medications at the resident's bedside. The Resident Care Director (RCD) or designee conducted an audit on 100% of residents who do not administer their own medications to verify medications are not present in their room without a physician's order or indicated on their ISP. Resident Care Director (RCD) or designee will conduct weekly resident room audits for one month and then monthly for three months to make sure proper storage of medications are being adhered to per policy and regulations. The results of resident room audits regarding proper storage of medications will be presented to the Quality Assurance and Performance Improvement Committee monthly for three months. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Executive Director or designee is responsible for implementation an ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur.
Standard #:	22VAC40-73-660-B
Description:	Based on observation and documentation, the facility failed to limit medication storage to an out-of-sight place in the rooms of residents whose UAIs have indicated that the residents are capable of self-administering their medication. Evidence: Medication administration for Resident #1 was observed during the inspection. Two bottles of Tylenol were observed on Resident #1?s shelf. Resident #1?s Uniform Assessment Instrument (UAI), dated 2/1/22, states that the resident needs her medication administered/monitored by professional nursing staff.
Plan of Correction:	Resident experienced no negative outcomes from having OTC Tylenol in her room. Team member who observed Tylenol in the room was re-educated on the policy for medications at the bedside on the day of inspection by the RCD. All Med Care Managers and Care Managers will be re-educated by the Resident Care Director (RCD) or designee on the policy for medications at the resident?s bedside. The Resident Care Director (RCD) or designee conducted an audit on 100% of residents who do not administer their own medications to verify medications are not present in their room without a physician?s order or indicated on their ISP. Resident Care Director (RCD) or designee will conduct weekly resident room audits for one month and then monthly for three months to make sure proper storage of medications are being adhered to per policy and regulations. The results of resident room audits regarding proper storage of medications will be presented to the Quality Assurance and Performance Improvement Committee monthly for three months. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur
Standard #:	22VAC40-73-680-M
Description:	Based on observation and interview, the facility failed to ensure that medications ordered for PRN administration are available and properly stored at the facility. Evidence: A PRN Glucagon emergency kit, ordered 5/10/22 for Resident #9, was not present at the time of the medication cart inspection. Facility staff confirmed that the medication was not present, at the time of the cart inspection.
Plan of Correction:	Resident experienced no negative outcome due to PRN glucagon not being available. Resident's order for PRN Glucagon was discontinued on 6/6/22 per physician's order. The Resident Care Director (RCD) or Designee re-educated the Wellness Nurses and Med Care Managers to monitor the availability of PRN medications for the residents per physician's orders. The Resident Care Director (RCD) or Designee audited 100% of the medication carts and PRN orders to verify their availability. The Resident Care Director (RCD) or Designee will perform weekly medication cart audits to monitor that PRN medications are available for one month and then monthly for three months. The results of the audit for the availability of PRN medications on medication carts will be presented to the Quality Assurance and Performance Improvement Committee monthly for three months. The results of the audit for the availability of PRN medications on medication carts will be presented to the Quality Assurance and Performance Improvement Committee monthly for three months. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur.
Standard #:	22VAC40-73-840-B
Description:	Based on documentation, the facility failed to ensure that pets living at the facility have regular immunizations. Evidence: Pet records were reviewed during the inspection. Pet #1?s rabies vaccination expired on 3/26/22.
Plan of Correction:	Not available online. Contact Inspector for more information.