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: Aug. 23, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced focused monitoring inspection was conducted on 8/23/23 to follow-up on a high-risk violation that was cited on 6/1/23. Resident records and facility documentation was observed. 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.

Violations:

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 instructions. Evidence: Resident #1?s record contained an order for Metoprolol, dated 12/15/21, that calls for the medication to be held when Resident #1?s heart rate is less than 60 and her systolic blood pressure (SBP) is less than 120. Resident #1?s MAR and progress notes state that her Metoprolol was held on the following dates when only one of the medication parameters was met: 8/23/23 (BP= 117/65; P= 63) 8/18/23 (BP= 115/61; P= 66) 8/18/23 (BP= 110/63; P= 66) 8/16/23 (BP= 116/63; P= 63) 8/9/23 (BP= 119/64; P= 63) 8/9/23 (BP= 118/62; P= 66) 8/5/23 (BP= 113/52; P=61) 8/4/23 (BP= 106/68; P= 61) 8/1/23 (BP= 115/64; P= 64)
Plan of Correction:	Resident #1 did not have any negative outcomes, and the physician changed order to remove parameters. The Resident Care Director (RCD) or designee completed an audit of residents' orders with parameters, and in conjecture with doctors' orders removed those that were not required. The RCD completed training with the Wellness Nurses, and Coordinator on order 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.