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: Feb. 23, 2022 and April 26, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Unannounced inspections were conducted on 2/23/22 and 4/26/22. Resident records and facility documents were reviewed. The allegations were determined to be valid, as a preponderance of evidence supported the allegations. The 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 #:	22VAC40-73-470-C
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that services are provided to prevent clinically avoidable complications. Evidence: Resident #2's record was reviewed during the inspection. A progress noted, dated 12/2/21, indicates that Resident #2 has a stage 2 sacral wound and that the resident should have frequent repositioning. Resident #2's individualized service plan (ISP) indicates that treatment to her pressure ulcer will be provided as ordered. The ISP did not document Resident #2's need for frequent repositioning. No additional documentation was provided to indicate that Resident #2 was frequently repositioned.
Plan of Correction:	A. With respect to the specific resident/situation cited: Resident #2 experienced no negative outcome to the sacral wound with the wound healed at the time of discharge (Dec. 2021). B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Resident Care Director/Designee retrained the clinical team on the importance of following treatment orders related to wound management with updates to the Care Plan. The Resident Care Director/Designee will review all wounds during the IDT meeting with the interdisciplinary team. C. With respect to what systemic measures have been put into place to address the stated concern: In order to confirm that the processes outlined above are sustained: The Resident Care Director and/or Designee will report audits of the electronic Medical Record that show supporting documentation related to wound treatment orders including Care Plan updates and the findings at the QAPI meeting for 90 days. After concluding the 90-day reviews, the QAPI committee will re-evaluate and initiate the necessary action needed at that time. D. With respect to how the plan of correction will be monitored: The Executive Director is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction; along with addressing and resolving variances that may occur.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on 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: Resident #1's medication administration record (MAR) was reviewed during the inspection. Resident #1's Iron and Vitamin D were not administered on 1/5/22. The MAR states that the medications were not administered, as they were "pending delivery." Resident #2's MAR was reviewed during the inspection. Resident #2's Losartan was not administered on 11/11/21. The MAR states that the Losartan was not administered, as it was "pending delivery." Resident #2's Oxycodone was not administered on 12/2/21 (3 AM administration). Resident notes stated that the medication was not administered, because the staff member was attending to three emergencies.
Plan of Correction:	A. With respect to the specific resident/situation cited: Residents #1 and #2 experienced no negative outcomes and medications are available for administration per physician?s orders. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Resident Care Director (RCD) conducted an eMAR medication cart audit to confirm medications were available per physician order. Any identified unavailable medication was reordered and arrival was confirmed. Resident Care Director (RCD) or designee conducted a refresher training with Medication Care Managers and Nurses regarding the process of timely ordering, reordering, and administration of prescribed medications. The Resident Care Director or designee will continue to conduct eMAR to medication cart audits weekly for 3 months to confirm that medications are available and administered per the physician?s order. 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 eMAR to medication cart audits weekly for 3 months to confirm that medications are available and administered per the physician?s order. The results of the audits will be presented by the resident care director and/or wellness designee at Quality Assurance and Performance Improvement (QAPI) meeting for 3 months. The resident Care 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: The Executive Director 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. Tracking and trending will take place in the monthly QAPI meeting.