VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise at Mount Vernon
8033 Holland Road
Alexandria, VA 22306
(703) 780-9800

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: Dec. 2, 2021

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 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:

An unannounced renewal inspection was conducted on 12/2/21 (8:45 AM - 6:10 PM). At the time of entrance, 80 residents were in care. Meals, medication administration, and an activity were observed. Building and grounds were inspected and records were reviewed. The sample size consisted of 10 resident records and five staff records. Violations were discussed and an exit meeting was held. 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 standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on record review, the facility failed to ensure that each resident is assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare, prior to his/her admission to the safe, secure environment. Evidence: The record for Resident #3 was reviewed during the inspection. Resident #3 was admitted into the safe, secure environment on 8/2/21. Resident #3's Assessment of Serious Cognitive Impairment form, dated 7/28/21, states that the resident has the ability to recognize danger or protect his own safety and welfare.
Plan of Correction:	The Primary Care Physician completed the Assessment of Serious Cognitive Impairment form for Resident #3. There was no negative outcome because of the form being completed incorrectly. The RCD and designee completed an audit of Residents medical records to verify the Assessment of Serious Cognitive Impairment form was completed by the physicians correctly; identified issues were addressed and resolved. The RCD and designee conducted a refresher training with the coordinators on verifying that the Assessment of Serious Cognitive Impairment form it is completed correctly. Upon receipt of an Assessment of Serious Cognitive Impairment form for a resident the RCD or designee will review the form to verify it is completed correctly; any identified issues are addressed and resolved. The RCD and/or designee will complete a medical record audit specific Assessment of Serious Cognitive Impairment form for the next 3 months to identify issues and ensure appropriate follow-up. 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.
Standard #:	22VAC40-73-680-D
Description:	Based on observation and record review, the facility failed to ensure that medications are administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: The morning medication administration for Resident #3 was observed during the inspection. Resident #3 received one 10mg tablet of Donepezil, during the medication administration. The record for Resident #3 includes an order for Donepezil, dated 8/11/21, that calls for the resident to receive two 10mg tablets.
Plan of Correction:	Resident #3 did not experience a negative outcome because of Donepezil (Aricept) was not administered per the physician's order. The Resident Care Director (RCD) notified the Nurse Practitioner who provided an order for a one-time dose of Aricept tablet so that resident #3 could receive the correct dose that day. The pharmacy was contacted by the RCD and issued a corrected label for the blister pack. The RCD and designee performed an audit of the medication orders with the pharmacy orders; identified issues were addressed and resolved. The RCD conducted a re-education training with the Medication Care Managers (MCM) on the process for clarifying discrepancies with medication orders. The RCD educated the Wellness Nurses and the MCM's on the process of reconciling medication orders when discrepancies are identified during medication administration. MCMs are to refer to the current medication orders in the medical records and obtain corrected medication labels when discrepancies are identified. The RCD conducts medication pass observations annually for MCM to verify medications are being administered according to administration practices. The MCMs conduct medication cart audits weekly to verify that medications labels match the medication orders. The RCD or designee conduct medication cart audits monthly to verify that medications labels match the medication orders. 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.
Standard #:	22VAC40-73-720-A
Description:	Based on record review, the facility failed to ensure that Do Not Resuscitate (DNR) Orders are included in the individualized service plan (ISP). Evidence: The record for Resident #2 was reviewed during the inspection. The record included a DNR order, dated 4/18/21. The DNR order was not included in Resident #2's ISP, dated 10/21/21, as she was listed as full code.
Plan of Correction:	Resident #3's ISP was updated to include current DNR order. The neighborhood coordinator educated resident #2's designated care managers on the resident's change DNR status. The Wellness Team and designee completed an audit of resident's ISPs to verify the DNR orders were documented correctly; identified issues were addressed and resolved. The RCD and designee conducted a refresher training with the wellness nurses and coordinators on properly documenting DNR orders on resident ISPs. As DNR orders are received the RCD or designee will review the orders and update the residents ISP. The designated care managers will be informed of the change. The RCD and/or designee will complete an audit to verify DNR orders are correctly documented on the ISP for up to 3 months. Any inconsistencies identified will be corrected. 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.
Standard #:	22VAC40-73-860-I
Description:	Based on observation, the facility failed to store cleaning supplies and other hazardous materials in a locked area. Evidence: The Beauty Salon was observed to be unlocked and unattended. Virex Tb disinfectant cleaner, Ship-Shape, and Casticide disinfectant cleaner were observed in the room, at the time of the inspection.
Plan of Correction:	The Maintenance Coordinator (MC) locked the Beauty Salon door. There were no negative outcomes. The MC replaced the door lock with a Schlage Coded Lock that automatically relocks after entry. The MC re-educated team members, including the beauty salon attendant, that the beauty salon closets, cabinets, and areas where chemicals are maintained need to be properly locked. The MC or designee checks to confirm that chemicals are properly stored and secured 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.