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: June 27, 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 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

Technical Assistance:

Documentation was discussed with the provider.

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: 6/27/22 (8:20 AM ? 6:45 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: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 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. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. 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 #:	22VAC40-73-680-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 June MAR (medication administration record) was reviewed during the inspection. Resident #1 receives Amlodipine Besylate at bedtime. Resident #1?s Amlodipine Besylate order, dated 3/9/22, states that the medication should be held when her systolic blood pressure is below 120. Resident #1?s MAR indicated that the medication was administered on 6/4/22, when her systolic blood pressure was 112. The medication was also documented as being administered on 6/11/22, when her systolic blood pressure was 116.
Plan of Correction:	Resident #1 did not experience any negative outcomes as a result Amlodipine Besylate administered on June 4th & June 11th. Resident's doctor was made aware. The Resident Care Director or Designee conducted an audit of residents with specific order parameter to verify the medication are administered according to the MD orders. The Resident Care Director or Designee conducted refresher training with the medication care managers and nurses regarding the process for administering medications according to physician's order. The Resident Care Director or designee will continue to conduct unannounced medication pass observations weekly for 3 months to confirm medications are given within the prescribed orders. Issues that may be identified will be addressed. 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-M
Description:	Based observation and documentation, the facility failed to ensure that medications ordered for PRN administration are available and properly stored at the facility. Evidence: Resident #4?s PRN Famotidine, Midazolam, and Tylenol suspension were not available for administration, at the time of the medication cart inspection. Facility staff confirmed that Resident #4?s PRN Famotidine, Midazolam, and Tylenol were not available for administration, at the time of the medication cart inspection.
Plan of Correction:	Resident #2 did not experience any negative outcome. PRN medication was ordered & refilled on 6/28. The WN completed an audit of the medication carts to verify PRN medications ordered were available. The RCD conducted a refresher training with the Medication Care managers on timely refilling process. The Resident Care Director and designee conducted eMAR & medication cart audit to confirm medications were available per physician's order. The RCD or designee will conduct audits of medication cart on monthly for 3 months to confirm that resident who has PRN orders are available. Issues identified will be resolved. 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.