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: Sept. 16, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND

Comments:

Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection (10:00 AM ? 11:50 AM) 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) of law. 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 #:	22VAC40-73-660-A-1
Description:	Based on observation and documentation, the facility failed to use a locked medicine cabinet, container, or compartment for the storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility. Medications shall be stored in a manner consistent with current standards of practice. Evidence: Wound ointment, ordered 4/22/22 for Resident #1, was observed to be unlocked and unattended in the resident?s bathroom. Resident #1?s UAI, dated 5/16/22, states that he needs his medication to be administered/monitored by professional nursing staff. Resident #1?s record contained an assessment of serious cognitive impairment, dated 8/3/21, 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:	No negative outcome occurred to residents with unsecured medications found. Medicated creams were removed and properly secured immediately. A whole house sweep of all resident suites was conducted. Team members were re-educated by RCD and ALC on procedures for safe storage of medications. Vendor contracted to update all memory care suite locks to ensure compliance. Reminiscence lead care manager and wellness nurse or designee to conduct weekly checks for next three months. All cabinet locks to be updated. RCD has communicated with hospice representatives regarding appropriate protocol for medicated creams. 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.
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: Nail polish remover and air freshener spray were observed to be unlocked and unattended in the shared bedroom of Residents #2 and #3, of the memory care unit. Resident #2?s record contained an assessment of serious cognitive impairment form, dated 9/1/21, that states that she has a serious cognitive impairment, and that she is unable to recognize danger or protect her own safety and welfare. Resident #3?s record contained an assessment of serious cognitive impairment, dated 3/19/19, 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 residents with unsecured chemicals found. Chemicals were removed and properly secured immediately.A whole house sweep of all resident suites was conducted. Team members were re-educated by Sr. M C on procedures for safe handling and storage of chemicals. Reminiscence lead care manager and wellness nurse or designee to conduct weekly checks for next three months. 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.