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: June 1, 2023

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

Comments:

An unannounced monitoring inspection was conducted on 6/1/23. At the time of entrance, 72 residents were in care. Meals, medication administration, and activities were observed. Building and grounds were inspected. Records were reviewed. The sample size consisted of 10 resident records and five staff records. Violations were discussed and an exit meeting was held. 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 #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure that each staff member annually submits the results of a tuberculosis risk assessment documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Tuberculosis risk assessments were not provided, during the inspection, for Staff #2 (hired 12/13/16) or Staff #4 (hired 3/3/23).
Plan of Correction:	Staff member #2 and #4 completed annual tuberculosis risk assessment and documentation are in employee's file. BOC or Designee completed an audit of TM files not surveyed, to verify compliance of initial and annual Tuberculosis risk assessment are completed within the required timeframe. BOC or Designee to complete a quarterly audit of TM files for TB risk assessments for 6 months. Issues identified will be resolved. The Executive Director or designee is responsible for confirming implementation and ongoing compliance components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-73-640-A
Description:	Based on record review, the facility failed to implement the medication management plan: methods to ensure that each resident's prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: Resident #11's May medication administration record (MAR) was reviewed during the inspection. Resident #11's MAR stated that her Galamantine was not administered on 5/17/23 and 5/18/23, as the medication was "pending delivery.? The MAR also stated that Resident #11?s multivitamin was not administered on 5/25/23 and 5/26/23, as the supplement was "pending delivery." Resident #11's notes indicated that the pharmacy was contacted to get additional information about the resident?s Galamantine on 5/16/23. No documentation was provided, during the inspection, to indicate whether Resident #11's physician was contacted for administration guidance regarding the Galamantine and multivitamin.
Plan of Correction:	No negative outcome to resident #11 as a result of missing Galamantine. RCD or Designee completed an audit of residents' medications administration and current supply. No other negative findings. The Resident Care Director (RCD) and the clinical team audited the medication orders and medication carts to confirm that medications prescribed were available per doctor's orders. Issues identified were resolved. The Well ness Nurses and Medication Care Managers (MCMs) were re-educated by the RCD regarding the process on reordering medication and what to do when a medication isn't available from the pharmacy. The RCD or designee will continue to audit physician orders for 3 months to confirm orders are present in the medication cart. Issues that may be identified will be addressed and resolved and refresher training initiated as needed. The results of the audits will be presented by the RCD or wellness designee at Quality Assurance and Performance Improvement (QAPI) meeting for 3 months. During and at the end of the 3 months, the QAPI Committee will evaluate the results of the medication orders and determine if additional focus or action is warranted. The Executive Director or designee is responsible for confirming implementation and ongoing compliance components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-73-720-A
Description:	Based on record review, the facility failed to ensure that Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation are included on the individualized service plan (ISP). Evidence: Resident #1's record contained a DNR order, dated 8/2/22. Resident #1's ISP, dated 4/3/23, lists the resident as full code. Resident #4's record contained a DNR order, dated 5/18/23. Resident #4's ISP, dated 5/19/23, lists the resident as full code. Resident #6's ISP, dated 4/7/23, states that the resident has a DNR order. No DNR order was observed in the record for Resident #6.
Plan of Correction:	Code status for resident's #1, #4 and #6 who were updated per Physician's order. Residents experienced no negative outcome. The Resident Care Director (RCD) or designee completed an audit of residents' code status to doctor's orders. Issues identified were resolved. The RDC completed training with the Wellness Nurses, and Coordinator on ISP requirements and compliance. Resident Care Director (RCD) or designee will conduct chart audits weekly for the next 3 months. Issues identified will be resolved. 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 #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to obtain a criminal history record report, from the Department of State Police within 30 days of hiring an employee. Evidence: The criminal history record reports were observed for new staff members. No criminal history record report was provided, during the inspection, for Staff #6 (hired 10/10/22).
Plan of Correction:	Criminal record check for staff member #6 is completed and in employee's files. BOC or Designee completed an audit of TM files not surveyed, to verify compliance of criminal background checks being completed within 30 days of hire and in staff members files. BOC will complete quarterly audits of new hires to confirm criminal background checks are in staff member files. During and at the end of 3 months, the QAPI committee will evaluate the results and determine if additional focus or action is warranted. The Executive Director or designee is responsible for confirming implementation and ongoing compliance components of this Plan of Correction and addressing and resolving variances that may occur.