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. 6, 2022

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 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:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/6/22 (8:30 AM - 6:00 PM) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were 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 #:	22VAC40-73-1090-A
Description:	Based on record review, the facility failed to ensure that each resident is assessed by an independent clinicalpsychologist 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, before they are admitted into the safe, secure environment. Evidence: The record for Resident #7 was reviewed during the inspection. Resident #7 was admitted into the memory care unit on 5/25/22, but the resident?s Assessment of Serious Cognitive Impairment was not completed until 5/27/22.
Plan of Correction:	The Primary Care Physician completed the Assessment of Serious Cognitive Impairment form for Resident #7. 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. 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 #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that each direct care staff member maintains certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. Evidence: The record of Staff #2 was reviewed during the inspection. Staff #2?s record contained a first aid certification that expired in October 2022. No documentation was provided, during the inspection, to confirm that Staff #2 has current certification in first aid.
Plan of Correction:	Staff #2 completed first aid training, on 12/13/2020, the certificate was provided to Surveyor on 12/14/2022. The Business Office Coordinator/Designee has reviewed the files of all team members responsible for direct care and ensured that each person has first aid and CPR training and that the training is current. The BOC and/or designee will audit new team members files monthly for three months to confirm that new team members have a current first aid certification, for staff identified first aid certification will be completed within 60 days of employment and required documentation placed in file. During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the Executive Director will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training in order to correct any deficient practices. The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and for addressing and resolving variances that may occur.
Standard #:	22VAC40-73-450-E
Description:	Based on record review, the facility failed to ensure that individualized service plans (ISPs) are signed and dated by the administrator, or their designee, and by the resident, or their legal representative. Evidence: The ISPs for the following residents were not signed by the resident or their legal representative: Resident #1 (dated 11/6/22), Resident #2 (dated 11/6/22), Resident #3 (dated 10/26/22), Resident #4 (dated 10/26/22), and Resident #8 (dated 8/25/22).
Plan of Correction:	The community reviewed the UAI and service plan for resident #1 and resident #2. The community agents signed the UAI and service plan, contacted the families of each resident, reviewed the service plan with the families, and had the families sign the plans. The Assisted Living Coordinator and Reminiscence Coordinator reviewed the files for all residents to ensure that the UAI and service plan for each resident has been completed according to policy and signed by the appropriate parties. Any plans found to be out of compliance with the associated regulation or company policy was addressed and corrected to comply. The care coordinators will be responsible for collecting signatures on the UAI and the ISP as new UAIs are completed. Newly completed UAIs and ISPs will be reviewed during Interdisciplinary Meetings that occur 2 to 3 times per month or as needed. The results of the review during the IDT meetings will be presented at the QAPI Meeting for 3 months. During and at the conclusion of each month, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. 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.
Standard #:	22VAC40-73-660-B
Description:	Based on observation and record review, the facility failed to limit medication storage to an out-of-sight place in the rooms of residents, whose UAI has indicated that the resident is capable of self-administering medication. The medication and any dietary supplements shall be stored so that they are not accessible to other residents. Evidence: Calmoseptine ointment was observed on a shelf in the room of Resident #2, of the memory care unit. Resident #2?s record contained an order, dated 7/28/22, for Calmoseptine ointment. Resident #2?s UAI, dated 11/3/22, states that the resident needs his medication to be administered by professional nursing staff.
Plan of Correction:	Resident #2 experienced no negative outcome from the medication left in the apartment unattended. The medication was removed from sight and was properly stored. The Executive Director/Designee spot checked 25% of the community?s occupied apartments for chemicals improperly stored and will present any violations at the monthly QAPI meeting. The Resident Care Director/Designee retrained the clinical team on the importance of following treatment orders related to medication storage starting at the all-team town hall conducted on 12/15/22. Reminiscence Coordinator/designee , will perform spot checks for unsecured medications and findings for 3 months, which will be presented at the QAPI meeting for 3 months. During the 3 months, the QAPI Team will re-evaluate and initiate necessary action or extend the review period, as needed based on issues identified or trends observed. The Executive Director or designee 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.