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: Oct. 31, 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: 10/31/22 (8:50 AM ? 12:55 PM) 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 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. 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 on observation, the facility failed to ensure that doors leading to the outside shall not be 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. Evidence: The main entrance door was unable to be opened from inside the building at 8:55 AM, during the inspection. The door was pushed for 15 seconds, an alarm sounded, and then the door was able to be opened. A keypad is located next to the door, and a code can be entered to release the door?s security. The Arlington County Fire Prevention Office was contacted about the facility?s permit to secure the entrance doors. The Fire Prevention 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 the residents to common areas and to their personal spaces. 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 Administrator/Executive Director will review the State code with Community leaders and team and ensure that resident in Assisted living has access to exit the community?s front door with ease 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. 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. The Executive Director and QAPI team are responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving any violation that may occur.
Standard #:	22VAC40-73-680-D
Description:	Based on observation and documentation, 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 October medication administration record (MAR) for Resident #1 was reviewed during the inspection. Resident #1 has an order for Amlodipine Besylate, dated 4/16/20, that calls for him to receive a 10mg tablet once per day. Resident #1 was not administered Amlodipine Besylate on 10/14/22. The MAR note stated that the resident?s vitals were outside the parameters. No parameters were included in Resident #1?s order for Amlodipine Besylate. The morning medication administration, for Resident #2, was observed during the inspection. Resident #2. Resident #2 has an order for Famotidine, dated 3/27/22, that calls for the resident to receive the medication every 12 hours. Resident #2 did not receive Famotidine during the medication administration, as it was not present in the medication cart. Resident #2?s MAR showed that there were 22 does of Famotidine that were not given, as the medication was ?pending delivery.?
Plan of Correction:	Resident Care Director received new order from physician and updated the Medication Administration Record (MAR) for Resident #1 on 10/31/22. Resident Care Director contacted pharmacy to notify pharmacy that Resident #2 was out of current scheduled medication as ordered on 10/31/22. Resident #2 did not exhibit adverse reaction from missed doses. Resident Care Director (RCD) /Wellness nurse (WN) /Medication Care Manager (MCM) will utilize the medication management plan and program, as outlined with the processes and procedure of medication administration. Resident Care Director (RCD) /Wellness nurse (WN) /Medication Care Manager (MCM) will follow up with pharmacy concerning any pending medications to confirm resident medications are available for administration. Resident Care Director (RCD)/ Wellness nurse (WN) conducted audits of the EMARs and Med Carts to confirm medications available and administered as scheduled per physician orders. Training will be completed by Resident Care Director with the Wellness nurse and Med Care Managers regarding the process and procedures for medication management. Training will be completed by Resident Care Director with the Wellness nurse and Med Care Managers regarding procedures for pending medications. Resident Care Director (RCD)/Wellness nurse (WN) will conduct random audits of the EMARs and Med Carts weekly x 4 weeks (11/29/22), monthly x 3 months (1/24/23) to confirm medications are available and administered as scheduled per physician orders. The RCD will present the results of the audits to the Quality Assurance and Performance Improvement (QAPI) Committee for three months. During and at the end of the three-month period, the QAPI Committee will evaluate the results of the audit and determine if additional focus or action is needed. Weekly, monthly, and quarterly Med cart audits will continue to confirm medications are available for administration. Review results in monthly Quality Assurance and Performance Improvement meetings. The Executive Director or Designee is responsible for the implementation and ongoing compliance with the components of the Plan of Correction as outlined.