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: Dec. 7, 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:

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: 12/7/23 (8:50 AM - 5:10 PM) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 67 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: 10 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. 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 #:	22VAC40-73-450-F
Description:	Based on observation and record review, the facility failed to ensure that the individualized service plan (ISP) is reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: Resident #1?s record was reviewed during the inspection. Resident #1?s ISP, dated 9/8/23, states that the resident receives hospice services, does not walk, and uses a hoyer lift for transfers. Progress notes, included in Resident #1?s record, indicate that he was walking independently on 10/27/23 and that he was discharged from hospice on 11/4/23. During the inspection, Resident #1 was observed walking and transferring without a hoyer lift.
Plan of Correction:	Resident #1's ISP was updated to reflect current functional status. The Resident Care Director (RCD) or designee completed an audit of current residents' ISPs to verify compliance with current resident condition. ISPs updated as needed. The RCD completed training with the Wellness Nurses, Care Coordinators on ISP requirements and compliance The RCD/Designee will conduct weekly audits for three months to verify ISPs compliance and report outcome to QAPI committee. During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the ED will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices. During and at the end of the three months, the QAPI Committee will evaluate the results and determine if additional focus or action is warranted. The Executive Director, RCD or designated 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 #:	22VAC40-73-680-I
Description:	Based on record review, the facility failed to ensure that all information is documented on the Medication Administration Record (MAR). Evidence: Resident #11?s MARs were observed during the inspection. Resident #11?s record contained an order for Metoprolol, dated 9/21/22, that calls for the medication to be held if the resident?s systolic blood pressure (SBP) is less than 100 and heart rate (HR) is less than 60. Resident #11?s MAR states that her Metoprolol was held on 11/15/23, 11/18/23, 11/22/23, 11/24/23, and 12/2/23 due to her vitals being outside of the parameters. Resident #11?s MAR did not contain the resident?s vitals for 11/15/23, 11/18/23, 11/22/23, 11/24/23, and 12/2/23. No documentation was provided, during the inspection, to identify what Resident #11?s vitals were on these dates.
Plan of Correction:	Resident #11 did not experience any negative outcome as a result of missed documentation. The Resident Care Director conducted audit to confirm proper documentation per physician's order. Refresher training with medication care managers and nurses was conducted by the Resident Care Coordinator regarding proper documentation per physician's order. The Resident Care Director or designee will continue to conduct documentation audits weekly for 3 months to confirm proper documentation per physician's order. 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, RCD or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.