VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise of Arlington
2000 North Glebe Road
Arlington, VA 22207
(703) 524-5300

Current Inspector: Ishmel Paige (804) 963-0360

Inspection Date: Aug. 5, 2024

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 GROUND 22VAC40-73 EMERGENCY PREPAREDNESS

Technical Assistance:

None

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: 08/05/2024 Time In: 10:48 AM Time Out: 4:57 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: 42 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: LI toured the physical plant of the facility. LI observed participants interacting with one another, dining for lunch and dinner, lounging in the common areas, and participating in activities, such as community outings. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. 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. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-240-F
Description:	Based on facility record review, the facility failed to ensure that prior to beginning volunteer service, all volunteers shall attend an orientation including information on their duties and responsibilities, resident rights, confidentiality, emergency procedures, infection control, the name of their supervisor, and reporting requirements. Volunteers shall sign and date a statement that they have received and understand this information. Evidence: 1. Staff 14 and Staff 15 did not sign and date a statement that they received orientation training. 2. On 08/5/2024, Staff 6 provided LI with a criminal background for Staff 14. Staff 6 stated that was all that they had. 3. On 08/5/2024, LI interviewed Staff 5 who stated they were in the process of recruiting more volunteers. Staff 15 is special needs, so they have not completed a criminal background or training since we sit with Staff 15 when they visit with the residents. Staff 5 stated Staff 14 went out of the country and when they return, they will do a training checklist. Staff 14 worked twice before going out of the country.
Plan of Correction:	A. With respect to the specific resident/situation cited: The community had no adverse outcomes due to 2 volunteers not having documented orientation and 1 volunteer not having a completed background check. Executive Director immediately educated the Activities and Volunteer Coordinator on the importance obtaining criminal background checks on volunteers and conducting and documenting orientation training with volunteers. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Activities Coordinator and Business Office Coordinator immediately began contacting volunteers to schedule orientation and obtain needed documents for criminal background checks . Criminal background check for staff #15 was received on 8/9/24. Activities Coordinator has not been able to reach staff #14 since she went out of the country on travel to conduct orientation. C. With respect to what systemic measures have been put into place to address the stated concern: The Executive Director, Activities and Volunteer Coordinator, or designee will continue to conduct audits monthly for 8 months to ensure all volunteers have been oriented and that the criminal background checks have been received. The results of the audits will be presented by the Executive Director and/or designee at Quality Assurance and Performance Improvement (QAPI) meeting for 8 months. The Executive Director will re-evaluate and initiate necessary action or extend the review period if necessary. D. With respect to how the plan of correction will be monitored: POC and monitoring results are reviewed and evaluated by the ED and coordinators at the Quality Management (Quality Assurance and Performance Improvement/QAPI) meeting for quarter four and quarter one to ensure it is still effective. If it is no longer effective, it will be amended and a new POC will be implemented and monitored to ensure the violation does not occur again.
Standard #:	22VAC40-73-610-B
Description:	Based on licensing inspector (LI) observation, the facility failed to ensure that menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents. Evidence: 1. On 08/5/2024, LI toured the facility and did not observe a posted weekly menu. 2. On 08/5/2024, LI interviewed Staff 4 who stated being unaware that the daily menu was not correct.
Plan of Correction:	A. With respect to the specific resident/situation cited: The residents had no known adverse reactions due to the menu not matching what was being served or being posted out for a week. Executive Director immediately educated the Dining Service Coordinator on the importance of posting accurate daily menus as well as weekly menus. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Dining Service Coordinator posted the weekly menu in the elevator . C. With respect to what systemic measures have been put into place to address the stated concern: The Executive Director, Dining Service Coordinator, and/or designee will conduct daily audits to ensure the menu matches the meal being served for 1 month. The Executive Director, Dining Service Coordinator, and/or designee will conduct monthly audits to ensure the menu matches the meal being served for 8 months. The results of the audits will be presented by the Dining Service Coordinator and/or designee at Quality Assurance and Performance Improvement (QAPI) meeting for 8 months. The Executive Director will re-evaluate and initiate necessary action or extend the review period if necessary. D. With respect to how the plan of correction will be monitored: POC and monitoring results are reviewed and evaluated by the ED and coordinators at the Quality Management (Quality Assurance and Performance Improvement/QAPI) meeting for quarter four and quarter one to ensure it is still effective. If it is no longer effective, it will be amended and a new POC will be implemented and monitored to ensure the violation does not occur again.
Standard #:	22VAC40-73-660-A-1
Description:	Based on licensing inspector (LI) observation, the facility failed to ensure that a medicine cabinet, container, or compartment shall be used for storage of medications and dietary supplements prescribed for residents when such medication and dietary supplements are administered by the facility. Medications shall be stored in a manner consistent with current standards of practice. Evidence: 1. On 08/05/2024, LI observed a medication pass. 2. Staff 3 (hire date, 7/24/2020) removed medications for Resident 3 (admit date, 07/26/2024). Staff 3 pushed the lock of the medication cart halfway so it could be opened without the use of keys. Staff 3 walked away to see if Resident 3 was in her room. 3. During the same medication pass, Staff 3 walked away from the medication cart, leaving it unlocked to go ask a question regarding Resident 3?s medication. LI prompted Staff 3 to lock the medication cart.
Plan of Correction:	A. With respect to the specific resident/situation cited: The resident had no adverse outcomes due to medication cart being left unlocked . The medication cart was locked and the MCM was notified. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns:locked when not in use. Resident Care Director (RCD) or designee conducted a medication administration refresher training with Medication Care Managers/ Nurses regarding HIPPA and medication diversion. C. With respect to what systemic measures have been put into place to address the stated concern: The Resident Care Director or designee will continue to conduct cart audits weekly for 3 months to confirm that medication carts are secured when not in use. Issues identified will be addressed and resolved. ED/RCD/Designee will observe carts through daily walk-throughs of the community to ensure they are locked daily for 2 weeks. The Resident Care Director or designee will continue to conduct a random audit weekly for 3 months to confirm that medications are secured when the cart is not in use . At the end of the audit, results from the audits will be presented by the resident care director and/or wellness designee at Quality Assurance and Performance Improvement (QAPI) meeting. D. With respect to how the plan of correction will be monitored: POC and monitoring results are reviewed and evaluated by the ED and coordinators at the Quality Management (Quality Assurance and Performance Improvement/QAPI) meeting for quarter four and quarter one to ensure it is still effective. If it is no longer effective, it will be amended and a new POC will be implemented and monitored to ensure the violation does not occur again.
Standard #:	22VAC40-73-680-G
Description:	Based on resident record review, the facility failed to ensure that over-the-counter medication shall remain in the original container, labeled with the resident?s name, or in a pharmacy-issued container, until administered. Evidence: 1. Resident 7 (admit date, 09/24/2019) had an order for Ascorbic Acid Tablet 500 MG, which is labeled Caltrate Soft Chews 600+D3 Bone Strength, an over-the-counter medication, was not labeled with Resident 7?s name. The medication only had the resident?s room number written on the packaging. 2. Video evidence taken.
Plan of Correction:	A. With respect to the specific resident/situation cited: Resident 7 had no adverse outcome due to over-the-counter medication only having been labeled with the room number and not the resident?s name. Resident Care Director promptly labeled OTC medications with each resident?s name and discussed with families the benefits of switching to Omnicare, where the pharmacy provides labeled, blister-packed OTC medications for safer handling during administration. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Resident Care Director (RCD) conducted eMAR to medication cart audit to confirm Over-the counter medications were properly labeled per physician?s orders. An in-service training with the Medication Care Manager (MCM) on procedure to follow when an over-the-counter medication is missing a label, to report to the Resident Care Director for proper action. C. With respect to what systemic measures have been put into place to address the stated concern: Resident Care Director (RCD) or designee will continue to conduct weekly audits of the med cart monthly for 3 months to verify that over-the-counter medications are properly labeled with the resident?s name per physician orders. Findings from audits will be resolved and taken to QAPI. D. With respect to how the plan of correction will be monitored: POC and monitoring results are reviewed and evaluated by the ED and coordinators at the Quality Management (Quality Assurance and Performance Improvement/QAPI) meeting for quarter four and quarter one to ensure it is still effective. If it is no longer effective, it will be amended and a new POC will be implemented and monitored to ensure the violation does not occur again.
Standard #:	22VAC40-73-830-E
Description:	Based on facility record review, the facility failed to ensure that the facility provided a written response to the council prior to the next meeting regarding any recommendations made by the council for resolution of problems or concerns. Evidence: 1. Resident Council meetings were held on 05/12/2024, 06/5/2024, and 07/2/2024. Residents expressed the need for resident handbook, issues with housekeeping, issues with dining service and food, and resident care issues. 2. Administration did not provide a written response to the residents prior to 06/25/2024 and 07/2/2024 meetings.
Plan of Correction:	A. With respect to the specific resident/situation cited: The residents had no known adverse outcomes due to lack of written response to resident council concerns. Executive Director immediately documented written responses and attached it to the resident council forms . B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Executive Director will conduct a review of all resident council notes to ensure a response was received. C. With respect to what systemic measures have been put into place to address the stated concern: The Executive Director or designee will continue to attend all monthly resident council meetings and document concerns brought up in resident council and Executive Director or designee will respond in writing to any concerns and report that back out at future resident council meetings. Executive Director or designee will conduct monthly audits for 8 months to ensure a written response has been documented for resident council each month. The results of the audits will be presented by the Executive Director and/or designee at Quality Assurance and Performance Improvement (QAPI) meeting for 1 year. The Executive Director will re-evaluate and initiate necessary action or extend the review period if necessary. D. With respect to how the plan of correction will be monitored: POC and monitoring results are reviewed and evaluated by the ED and coordinators at the Quality Management (Quality Assurance and Performance Improvement/QAPI) meeting for quarter four and quarter one to ensure it is still effective. If it is no longer effective, it will be amended and a new POC will be implemented and monitored to ensure the violation does not occur again.
Standard #:	22VAC40-73-950-E
Description:	Based on facility record review, the facility failed to ensure that the facility developed and implemented an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual?s respective responsibilities. The review should be documented by signing and dating. Evidence: 1. The emergency preparedness plan was reviewed with 10 staff members on 07/29/2024. The staff list reflects 46 employees. 2. On 08/5/2024, LI interviewed Staff 6 who stated I just started working on it, so I haven?t reviewed it with all staff. I only got to those 10. This is the only review I have since the last licensing inspection.
Plan of Correction:	A. With respect to the specific resident/situation cited: The residents had no adverse outcomes due to the Emergency Preparedness Plan not being reviewed by 46 staff members. Executive Director immediately held a review of the Emergency Preparedness Plan with staff present in the community. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Executive Director and/or designee will conduct quarterly Emergency Preparedness Plan reviews with the staff as well as ensure new hires review the Emergency Preparedness Plan with the Executive Director or designee. The Executive Director and/or designee with conduct quarterly audits to ensure staff have reviewed the Emergency Preparedness Plan. C. With respect to what systemic measures have been put into place to address the stated concern: The QAPI meetings will include tracking and trending of quarterly Emergency Preparedness Plan reviews with current staff. During and after each quarter, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. D. With respect to how the plan of correction will be monitored: POC and monitoring results are reviewed and evaluated by the ED and coordinators at the Quality Management (Quality Assurance and Performance Improvement/QAPI) meeting for quarter four and quarter one to ensure it is still effective. If it is no longer effective, it will be amended and a new POC will be implemented and monitored to ensure the violation does not occur again.
Standard #:	22VAC40-73-970-E
Description:	Based on facility record review, the facility failed to ensure that a record of the required fire and emergency evacuation drills shall be kept in the facility for two years. Evidence: 1. Upon request, the facility did not provide evidence of the completion of emergency evacuation drills for July ? December 2023. 2. January ? August 2024 fire drill logs did not contain documentation of the number of residents participating and special conditions. 3. January, March, April, and August of 2024 fire drill logs did not contain documentation of weather conditions. 4. January 2024?s fire drill logs did not contain documentation of the identity of the person conducting the drill. 5. February 2024?s fire drill logs did not contain documentation of the date and time of the drill. 6. February and March of 2024 fire drill logs did not contain documentation of the time it took to complete the drill.
Plan of Correction:	A. With respect to the specific resident/situation cited: The residents had no adverse outcomes due to fire and emergency evacuation drills not being accurately and appropriately documented to include weather conditions, person conducting the drill, and the number of residents participating. Executive Director immediately educated the Maintenance Coordinator on the importance keeping records of monthly emergency evacuation drills organized and easy to obtain in the emergency drills binder, documenting the weather conditions on the report each time a drill is ran, and documenting the number of residents participating. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Executive Director conducted an emergency evacuation drill refresher training with Maintenance Coordinator. C. With respect to what systemic measures have been put into place to address the stated concern: The Executive Director or designee will continue to conduct emergency evacuation drills monthly. Monthly audits to confirm all drills are documented and filed away and include the weather conditions and number of residents who participated will be done every month for 8 months. The Executive Director or designee will continue to conduct documentation audits monthly for 8 months to ensure that monthly drills are documented accurately and filled away appropriately. The results of the audits will be presented by the Maintenance Coordinator, ED, or designee at Quality Assurance and Performance Improvement (QAPI) meeting for 8 months. The Executive Director will re-evaluate and initiate necessary action or extend the review period if necessary. D. With respect to how the plan of correction will be monitored: POC and monitoring results are reviewed and evaluated by the ED and coordinators at the Quality Management (Quality Assurance and Performance Improvement/QAPI) meeting for quarter four and quarter
Standard #:	22VAC40-73-980-H
Description:	Based on licensing inspector (LI) observation, the facility failed to ensure the availability of 96-hour supply of emergency food and drinking water. At least 48 hours of supply must be on site at any given time, of which the facility?s rotating stock may be used. Evidence: 1. The emergency water expired March 2024. 2. On 08/5/2024, LI interviewed Staff 4 who stated, we ran out of emergency water; it expired. I pulled it and we will get more tomorrow, if I get the order in by 3 pm. I checked the emergency food and water once a month. The food should last us a month. 3. On 08/5/2024, during the findings review, Staff 4 showed LI where the order for emergency water was submitted.
Plan of Correction:	A. With respect to the specific resident/situation cited: The community had no adverse outcome due to not have a 96 hour supply of non-expired water. Executive Director immediately educated the Dining Service Coordinator on the importance of having a 96-hour supply of water available at the community at all times. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Dining Service Coordinator ordered new supply of water on 8/5/2024 and water was received on 8/12/24 and water expires on 1/21/2026. C. With respect to what systemic measures have been put into place to address the stated concern: The Executive Director, Dining Service Coordinator, or designee will conduct audits quarterly to ensure a 96-hour supply of emergency food and water is always available in the community. The results of the audits will be presented by the Executive Director and/or designee at Quality Assurance and Performance Improvement (QAPI) meeting for 1 year. The Executive Director will re-evaluate and initiate necessary action or extend the review period if necessary. D. With respect to how the plan of correction will be monitored: POC and monitoring results are reviewed and evaluated by the ED and coordinators at the Quality Management (Quality Assurance and Performance Improvement/QAPI) meeting for quarter four and quarter one to ensure it is still effective. If it is no longer effective, it will be amended and a new POC will be implemented and monitored to ensure the violation does not occur again.