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 15, 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 GROUNDS 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 6/15/23. At the time of entrance, 67 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. The violation was 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. Changed to monitoring inspection upon administrative review

Violations:

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 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 morning medication administration, for Resident #8, was observed during the inspection. Resident #8's medications were removed from their medication packages, and placed in a pill sleeve to be crushed. Resident #8's medications were crushed and administered in yogurt. Protonix, ordered 9/21/22, was one of the medications that was crushed and administered. The Protonix medication package states that the medication should not be crushed.
Plan of Correction:	Upon receiving the medication RCD or Wellness Nurse need to check them in and make sure they are on the MAR, at that time they should verify the package instructions and the MAR instruction. RCD reviewed all the residents with Protonix orders and updated the administrator notes in e-MAR reflecting Do not crush medication. MCM to double check when passing medications. The Resident Care Director will continue to conduct weekly MAR to cart audits for the next three months, so they can catch anything that was done incorrectly. The POC will be reviewed for the next three 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.