VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise at Hunter Mill
2863 Hunter Mill Road
Oakton, VA 22124
(703) 255-1006

Current Inspector: Alexandra Roberts

Inspection Date: Dec. 2, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 12/2/22 (8:01 AM ? 11:50 AM) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. An exit meeting will be conducted to review the inspection findings. 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. 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 #:	22VAC40-73-530-B
Description:	Based observation, the facility failed to ensure that doors leading to the outside are not locked from the inside or secured from the inside in any manner that amounts to a lock, except that doors may be locked or secured in a manner that amounts to a lock in special care units as provided in 22VAC40-73-1150 A. Any devices used to lock or secure doors in any manner must be in accordance with applicable building and fire codes. Evidence: Upon the licensing inspector?s arrival at the facility at 8:01 AM, the facility?s front door was unable to be opened from outside the building. Shortly after the inspector arrived, a visitor attempted to exit the building using the front door. He pushed on the door, but it would not open. The visitor stated that he was unable to open the door, as he did not have the code for the door. No staff members were present to open the door, and the visitor pushed on the door for 15 seconds, in order for the door?s security to be released. After the door was opened, a staff member was located and informed about the door. Facility staff reported that a staff member was supposed to be present to open the door for visitors. There is a device that would allow the staff member to disengage the door?s security, so that it can be freely opened. The Fairfax Fire Marshal?s office was contacted about the facility?s permit to secure the front doors. The Fire Marshal?s representative reported that their office did not have a permit on file, for the facility to secure doors that lead outside.
Plan of Correction:	The facility shall provide freedom of movement for all the residents. The facility shall not lock doors leading to the outside of the community and doors shall not be locked from the inside or secured from the inside in any manner. The Executive Director is working along with the State Code and related department to get the issue resolved as soon as possible. In the meantime, the community leader will ensure that residents in Assisted living will have the freedom to exit/enter building with no restrictions during business hours. The Executive Director and Maintenance Coordinator will review and will have a front door security that allows for the front door in the community to be opened during normal business hours. Additionally, residents have been notified during the resident council meeting about door being unlocked during normal business hours. Residents were also encouraged to utilize the sign out books for the safety purpose. Families are to be notified of the change in our weekly communication via email. The leadership team (Executive Director, QAPI Team) will evaluate the results/process to determine if additional focus or action is warranted during Monthly Quality Assurance and Performance Improvement (QAPI) meetings. During and after the 3 months, the QAPI Team will re-evaluate and initiate necessary action or extend the review period, as needed based on issues identified or trends observed. 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 to correct any deficient practices.
Standard #:	22VAC40-73-680-D
Description:	Based on 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 medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Resident #1?s November MAR (medication administration record) was reviewed during the inspection. Resident #1 receives Eliquis twice per day. The MAR states that Resident #1?s Eliquis wasn?t administered on 11/21/22, 11/22/22, or 11/23/22. Resident #1?s morning administration of Eliquis was also not administered on 11/24/22. The MAR listed Resident #1?s Eliquis as a ?medication pending delivery,? on those dates.
Plan of Correction:	Resident #1 did not experience any negative outcomes as a result of Eliquis not being administered. Medication is available for administration per physician's orders. The Resident Care Director conducted e-MAR to medication cart audit weekly for 3 months to confirm that medications are available and administered per the physician's order. The Resident Care Director conducted a training with Wellness Nurses and Med techs regarding proper follow ups on pending medication deliveries. Resident Care Director and Wellness nurse will follow up with pharmacy concerning any pending medications to confirm resident medications are available for administration. The Resident Care Director or designee will continue to conduct e-MAR to medication carts audits weekly for 3 months to confirm that medications are available and administered per the physician's order. The results of the audits will be presented by the Resident Care Director and/or wellness designee at Quality Assurance and Performance Improvement (QAPI) meeting for 3 months. The Resident Care Director will re-evaluate and initiate necessary action or extend the review period if necessary. The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur. Tracking and trending will take place in the monthly QAPI meeting.