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: April 26, 2022

Complaint Related: Yes

Areas Reviewed:

PART VI. RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced complaint inspection was conducted on 4/26/22. The allegations were determined to be valid, as a preponderance of evidence supported the allegation. The violation was 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, please contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-460-B
Complaint related:	Yes
Description:	Based on documentation, the facility failed to ensure a prompt response by staff to resident needs as reasonable to the circumstances. Evidence: Facility call bell documents were reviewed during the inspection. The facility?s call bell system does not provide information about the reason for the call, when the call button is pushed or the call cord is pulled. Resident #1?s April 2022 call bell report indicated that the bell or cord was used 50 times. The report indicated that there were 19 instances when staff members took at least 30 minutes to acknowledge the call bell, or the alert was never responded to. Resident #2?s April 2022 call bell report indicated that the bell or cord was used 119 times. The report indicated that there were 64 instances when staff members took at least 30 minutes to acknowledge the call bell, or the alert was never responded to.
Plan of Correction:	Residents #1 and #2 experienced no negative outcomes and was provided assistance. The call bell pull stations and pendants were tested to ensure batteries are in working order by the Maintenance Coordinator. The Executive Director (ED) conducted an in-services on-call bell management and how vital it is to the life-safety of residents. The Maintenance Coordinator or designee will continue to conduct random call bell audits weekly for 3 months to confirm that call bells are responded to timely. The Call bells will be pulled randomly by the Maintenance Coordinator or Designee and response time noted starting on 5/30/22. Issues identified will be addressed and resolved timely. Any pulls that do not register accordingly will be reported to the vendor for resolution. This audit will be done weekly for 3 months to identify any concerns. 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.