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: Feb. 27, 2023

Complaint Related: No

Areas Reviewed:

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

Comments:

An unannounced focused-monitoring inspection was conducted on 2/27/23 to follow-up on high-risk violations that were cited on 12/2/22. Medication administration and resident records were observed. Building and grounds were inspected. 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. 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 #:	22VAC40-73-650-B
Description:	Based on record review, the facility failed to ensure that physician or other prescriber orders, both written and oral, include the strength of each medication and supplement. Evidence: The morning medication administration, for Resident #2, was observed during the inspection. Resident #2?s order, for Vitamin D2, did not include the strength of the supplement.
Plan of Correction:	Resident #2's e-MAR was updated to include the strength of the supplement. The RCD verified all medications on the resident e-MAR indicate include the strength. The Resident Care Director conducted an audit of e-MARs to verify that prescribed medications include the strength. The Resident Care Director re-educated wellness nurses on proper transcription of orders in e-Mar to include the strength for each medication prescribed. The Resident Care Director or designee conducts monthly e-mar to cart audits to verify that prescribed medications include the strength on the order. The POC will be reviewed for the next 3 months during the Quality Assurance and Performance Improvement meeting to verify that it is effective. 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.
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: The morning medication administration was observed, for Resident #1, during the inspection. Resident #1?s Synthroid was administered at approximately 8:27 AM. The medication package stated that it should be given on an empty stomach. At approximately 8:50 AM, Resident #1 was observed eating breakfast. Resident #1?s Synthroid was not administered at least one-half to one hour before eating breakfast.
Plan of Correction:	Resident #1 was evaluated by the Resident Care Director; the resident did not experience any negative outcomes. The Resident Care Director conducted an audit for residents prescribed Synthroid, to verify that the medication is scheduled on the e-MAR and medication label to be administered per Physician orders. Any issues identified were resolved. The Resident Care Director conducted a refresher training with the wellness nurses on order verification and transcribing into the e-Mar upon the orders being received. Any concerns identified during the process to be addressed with the provider immediately. The POC will be reviewed for the next 3 months during the Quality Assurance and Performance Improvement meeting to verify that it is effective. 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.