VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise Assisted Living at Fair Oaks
3750 Joseph Siewick Drive
Fairfax, VA 22033
(703) 264-0506

Current Inspector: Marshall Massenberg (804) 543-5188

Inspection Date: Sept. 27, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Licensing Inspector (LI) conducted unannounced complaint investigation on 9/27/2019 regarding resident care and alleged neglect. LI reviewed resident record, medication administration records, and staff record. Interviews were conducted with Interim Executive Director, Reminiscence Coordinator and Director of Nursing. Additionally staff interview notes from another government social agency were reviewed. The complaint is deemed valid as a preponderance of evidence gathered during the investigation supported the allegations. The exit interview was conducted on 9/27/2019 and the violation notice regarding the standards deemed valid was emailed to the facility on 10/10/2019 for completion of the plan of correction. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-4708 or contact me via email at lynette.storr@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-430-H-1
Complaint related:	No
Description:	Facility failed to ensure that at the time of discharge, the assisted living facility shall provide to the resident and, as appropriate, his legal representative and designated contact person a dated discharge statement. Evidence: Resident #1 was discharged from the facility on 8/30/2019. There was no documentation to indicate that discharge statement was completed.
Plan of Correction:	A Wellness Nurse documented in Resident #1?s Health Record a discharge note, which included a comprehensive assessment, vital signs, medication instructions, and that the resident is moving home with the daughter. The ALC conducted an audit of residents who moved out of the community during the past 30 days to confirm documentation of discharge statements and that residents and legal representatives were sent a copy of the discharge statement. Issues identified are being addressed and resolved. The ED will issue discharge statements to residents and legal representatives when residents move out. The Business Office Coordinator (BOC) or designee will continue to conduct audits of resident discharge medical records to confirm documentation of discharge statements and that resident and legal representatives are being sent the statements. The BOC or designee will present the results of the initial audit and then subsequent audits to the QAPI committee for 3 months. During and at the end of the 3 months, the QAPI committee will evaluate the results of the audits and determine if additional focus or action is warranted. The Executive Director is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-73-550-C
Complaint related:	Yes
Description:	Facility failed to ensure that any resident of an assisted living facility has the rights and responsibilities as provided in ? 63.2-1808 of the Code of Virginia and this chapter; specifically the right that ensures that the resident is free from mental, emotional, physical, sexual, and economic abuse or exploitation; is free from forced isolation, threats or other degrading or demeaning acts against him; and his known needs are not neglected or ignored by personnel of the facility. Evidence: Staff #1 and Staff #2 were present during a one hour training facilitated by the manufacturer addressing the correct use of the sit to stand adaptive equipment. The training instructed staff that three straps should be used when transferring a resident using this piece of equipment. On 4/21/2019 a family member observed Staff #1 and Staff #2 using only two straps to complete a transfer and the resident had subsequently landed on the floor. At this time the staff were reported to the supervisor and were verbally counseled regarding the requirement of three straps. Based on interviews it was determined that Staff #2 after being trained and verbally counselled repeatedly ignored the instruction to use three straps and continued to use only two straps putting the resident in danger of being injured.
Plan of Correction:	Resident #1 was assisted to the floor during the sit to stand equipment transfer by Staff#1 and Staff#2. A Nurse assessed the resident and observed no adverse outcome. Reminiscence Coordinator provided refresher training to Staff #1 and Staff #2 in regards to transferring residents with sit to stand mechanical lifts. Resident no longer resides at the community. Staff # 2 is no longer employed at the community. There are currently no residents using Sit to Stand equipment for transfers. The Health Pro Physical Therapy team conducted refresher training beginning 10/25/19 for care team members regarding transferring techniques and use of mechanical assistive devices. In addition, the Resident Care Director, Assisted living Coordinator and Reminiscence Coordinator are receiving ?train the trainer? instruction from a Health Pro Physical Therapist so that they may continue to conduct training for care team members as orders for mechanical lift transfers are received for residents. The Assisted Living Coordinator (ALC) or Reminiscence Coordinator (RC) or designee will conduct unannounced weekly observations of care managers performing transfers of residents using mechanical assistive devices to confirm that are following manufacturer protocols. Issues identified will be addressed and resolved and refresher training initiated if needed. The ALC or RC or designee will present the results of the initial observations and then subsequent observations to the QAPI committee for 3 months. During and at the end of the 3 months, the QAPI committee will evaluate the results of the observations and determine if additional focus or action is warranted. The Executive Director is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.