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: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/23/23 (1:45 PM - 5:30 PM). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 7/25/23 regarding an allegation in the area of: Resident Care and Related Services. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 2 The evidence gathered during the investigation supported the complaint of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-460-B
Complaint related:	Yes
Description:	Based on documentation, the facility failed to ensure a prompt response by staff to resident needs as reasonable to the circumstances. Evidence: Call bell reports (for 30 days) were reviewed for Residents #1, #2, and #3. Resident # 1's call bell report indicated that there were five occasions when it took staff at least 20 minutes to respond to the resident's call bell (out of 36 call alarms). Resident #2?s call bell report indicated that there were 41 occasions when it took staff at least 20 minutes to respond to the resident?s call bell (out of 314 call alarms). Resident #3?s call bell report indicated that there were seven occasions when it took staff at least 20 minutes to respond to the resident?s call bell (out of 82 call alarms).
Plan of Correction:	No negative outcome to residents' #1, #2, and #3 as a result of excessive call bell responses. ED or Designee completed an audit of residents' call response times with no other violations. The ED or designee will continue to audit resident call bells for 3 months to confirm response times are not unreasonable to circumstances. 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 ED or 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 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.