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: Aug. 17, 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 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:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/17/22 (8:30 AM ? 6:30 PM) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 41 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 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. Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that direct care staff members maintain 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. Each direct care staff member who does not have current certification in first aid, shall receive certification in first aid within 60 days of employment. Evidence: The record for Staff #2, hired 6/17/22, was reviewed during the inspection. No documentation was provided, during the inspection, to indicate that Staff #2 received first aid certification within 60 days of being hired.
Plan of Correction:	Facility (BOC office) will ensure a periodic (monthly/quarterly) review of team member?s files to ensure that all staff files have the needed and required documentations/records. At the time of the inspection, Staff #2 had CPR but no First Aid: She was scheduled for CPR and First Aid on 08/24/22. As of 8/24/22, Now Staff #2 is certified in both CPR and Frist Aid. Moving forward facility will be on top of with 60 days requirement by routinely and frequently auditing of new team Member files. The Business Office Coordinator will review and audit team member and new hire files to ensure that all required standards pertaining to CPR/First Aid are met in accordance with State regulations. The Business office Coordinator will review Team members file Bi-monthly to confirm they reflect the standards required. On a quarterly review, the leadership team will evaluate the results of the reviews and determine if additional focus or action is warranted during Monthly Quality Assurance and Performance Improvement (QAPI) meetings. The Executive Director and QAPI Team is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur. During and at the end of each quarterly review, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results and determine if additional focus or action is warranted.
Standard #:	22VAC40-73-680-D
Description:	Based on observation and 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: The August medication administration record (MAR) for Resident #1 was reviewed during the inspection. Resident #1 has an order for insulin, dated 4/6/22, that called for her to receive 5 units of insulin before meals. During the morning medication administration on 8/3/22, Resident #1 was not administered insulin. The MAR note stated that she was to receive no coverage. No parameters, for insulin administration, were included on the order. No instructions were provided, during the inspection, to indicate why the insulin was during the morning administration on 8/3/22. The August medication administration record (MAR) for Resident #9 was reviewed during the inspection. Resident #9?s MAR indicated that her Levothyroxine, ordered 7/13/22, was not available for administration on 8/10/22 and 8/11/22. The MAR note stated that the medication was ?pending delivery.?
Plan of Correction:	There were no negative outcomes as a result of Resident # 1 not receiving medication timely and Resident #9 insulins parameter. The Resident Care Director has called the MD for verification and parameter order to hold insulin in the event of low blood sugar for Resident #1. Resident #9 had an order from an outside MD for Levothyroxine, Resident Care Director has validated and reviewed each order for accuracy and inconsistency. The Resident Care Director and Med Techs has reviewed the standards regarding insulin injections and audit of written orders to identify incorrect orders/prescription from MD; this process will be an ongoing and routine. Team member was counseled, and Med Techs reviewed policy and procedures on orders and to refer to MD orders on eMAR. The Resident Care Director, or Wellness Nurse is completing Med audits each month to confirm they reflect the needs/prescriptions for care of each resident. The leadership team Executive Director, QAPI Team) will evaluate the results of the Med reviews and determine if additional focus or action is warranted during Monthly Quality Assurance and Performance Improvement (QAPI) meetings. The Resident Care Director or designee will present the results of the medication cart audits to the Quality Assurance and Performance Improvement (QAPI) Committee for 3 months. During and at the end of the 3 months the Quality Assurance and Improvement Committee will evaluate the results of the EMAR to medication cart audits and determine if additional focus or action is warranted. The ED 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.
Standard #:	22VAC40-90-40-G
Description:	Based on record review, the facility failed to ensure that a criminal history record report is obtained, on or prior to the 30th day of employment, for each employee. Evidence: The criminal history record reports of new staff members were reviewed during the inspection. One out of 13 new staff records (Staff #5) did not contain a criminal history record report. Staff #5 was hired on 8/27/21.
Plan of Correction:	Facility will ensure a periodic (monthly/quarterly) review of team member?s files to ensure that all staff files have the needed and required documentations/records. Moving forward BOC will audit team member files consistently. At the time of the inspection, a state background check was conducted for Staff #5 (08/17/22), was presented to the inspector and was accepted, then placed on Staff #5?s file. The Business Office Coordinator is reviewing and auditing team member and new hire files to ensure that all required documentation and standards pertaining to criminal background are met in accordance with State regulations. The Business office Coordinator (BOC) will review Team members file Bi-monthly to confirm they reflect the standards required. On a quarterly review, the leadership team will evaluate the results of the reviews and determine if additional focus or action is warranted during Monthly Quality Assurance and Performance Improvement (QAPI) meetings. The Executive Director and QAPI Team is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving any violations that may occur. During and at the end of each quarterly review, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate that, all new TM files will be viewed/signed by The Executive Director before they are filed in the BOCs office.