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: July 22, 2022 , Aug. 4, 2022 , Aug. 11, 2022 and Aug. 23, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Unannounced complaint inspections were conducted on 7/22, 8/4/, 8/11, and 8/23. The inspections were in response to a complaint received by the licensing office on 5/26/22 regarding Resident Care and Related Services. Interviews were conducted, staff records were observed, and resident records were observed. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and the violation was 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-580-E
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber be provided according to his instructions and documented. Evidence: Resident #1?s resident record was observed during the inspection. Resident #1?s record contained an order for Calmoseptine ointment, dated 3/31/22. Resident #1?s ISP states that Resident #1 needs assistance with medication administration and assistance to the bathroom. No documentation was provided, during the inspection, to document the administration of Calmoseptine to Resident #1, during his time at the facility in July. Resident #2?s resident record was observed during the inspection. Resident #2?s record contained an order for Ketoconazole shampoo, dated 10/11/21. Resident #2?s ISP states that the resident needs assistance with bathing, medication administration and grooming. No documentation was provided, during the inspection, to document the administration of Resident #2?s Ketoconazole shampoo in July.
Plan of Correction:	Residents #1 and #2 experienced no negative outcomes. Resident Care Director (RCD) immediately communicated the importance of verifying all orders are being followed to the registered medication aides, wellness nurses, and care managers. Resident Care Director (RCD) or designee conducted a medication refresher training with Medication Care Managers/Nurses regarding following orders and documentation. The Resident Care Director or designee will continue to conduct documentation audits weekly for 3 months to confirm that medications are being administered per the physician's order. The Resident Care Director or designee will continue to conduct documentation audits weekly for 3 months to confirm that medications are administered and that staff initials found for the application of prescribed medications are noted. 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. 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.