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: Sept. 6, 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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 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:

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: 9/6/23 (8:15 AM - 5:30 PM) Number of residents present at the facility at the beginning of the inspection: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. An exit meeting was held. Number of resident records reviewed: 6 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 2 Observations by licensing inspector: Meals, medication administration, activities 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.

Violations:

Standard #:	22VAC40-73-1110-B
Description:	Based on record review, the facility failed to ensure that a review of continued appropriateness, is completed six months after a resident is placed in the safe, secure environment. Evidence: The record for Resident #3, admitted 10/10/22, was reviewed during the inspection. Resident #3's record contained a review of continued appropriateness, dated 8/30/23. Resident #3's record did not contain a review of continued appropriateness, six months after the resident was placed in the safe, secure environment.
Plan of Correction:	The Executive Director completed a review of continued appropriateness after a resident is placed in the safe, secure environment on 8/20/23. This review of appropriateness of continued residence in special care unit was placed in Resident #3's file. An audit of current memory care resident's review of continued appropriateness of continued residence in special care unit was performed on 8/30/23 to verify each resident has a review of appropriateness of continued resident in special care unit was placed in resident files. Resident Care Director and Neighborhood Coordinators have been trained to verify that current memory care residents are reviewed for appropriateness of continued residence of special care unit and that current review of continued appropriateness form are completed at least every six months. Quarterly audits for three quarters, will be conducted by the Resident Care Director and/or Executive Director to verify each resident in memory care has a current review of continued appropriateness form. During the QAPI meeting and up to three months following the implementation of the POC, the Executive Director will review the POC and the results of the audit with the Department Coordinators. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
Standard #:	22VAC40-73-680-D
Description:	Based on 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: Resident #7's MARs (medication administration records) were reviewed during the inspection. Resident #7's MAR stated that the resident was administered Midodrine on 8/6/23 (BP: 149/86) and 8/24/23 (BP: 135/88). Resident #7's MAR calls for her Midodrine to be held, if her SBP is greater than 120.
Plan of Correction:	Resident Care Director (RCD) provided 1:1 in-service/training to Medication Care Manager (MCM) on "giving medication with parameters" on the Electronic Medication Administration Record (eMAR) for Resident #7 on 9/13/23. Resident Care Director (RCD) will conduct audits of the eMARs to verify that medications are administered within parameters per physician orders. Training will be completed by Resident Care Director with the Med Care Managers regarding the process and procedures for medication management with parameters. 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 audits to confirm medications are administered within parameters per physician order. Review results in monthly Quality Assurance and Performance Improvement (QAPI) meetings. The Executive Director or Designee is responsible for the implementation and ongoing compliance with the components of the Plan of Correction as outlined.
Standard #:	22VAC40-73-880-B
Description:	Based on observation and interview, the facility failed to ensure that space heaters are only used to supplement or provide heat, in the event of a power failure or similar emergency. Evidence: A space heater was observed in the room of Resident #8. Facility staff reported that there had been no recent power outages or similar emergencies.
Plan of Correction:	The facility shall ensure that space heaters are only used to supplement or provide heat, in the event of a power failure or similar emergency by removing the space heater observed in resident #8's room. The Executive Director will review the State code with Community leaders and team. The Resident Care Coordinator will coordinate room sweeps weekly with care staff to verify that no space heaters are present in resident rooms. The Executive Director, Resident Care Coordinator, and 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.