VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise Assisted Living of McLean
8315 Turning Leaf Lane
Mclean, VA 22102
(703) 734-1600

Current Inspector: Alexandra Roberts (804) 845-6956

Inspection Date: June 3, 2024

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of Inspection: Renewal Inspection Date of Inspection: June 3, 2024 thru June 5 2024 - 8am - 5pm 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: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: The LI observed medication administration, residents eating lunch and participating in other scheduled activities. 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 applicant has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to 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. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website should the facility be issued a license to operate. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.n.roberts@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-550-G
Description:	Based on record review and staff interview, facility failed to ensure that Resident Rights are reviewed annually with each resident or his legal representative or responsible individual. Evidence: 1. Resident 1?s record (DC?d 5/25/2024) last resident rights was dated 04/28/2023. 2. Resident 3 and resident 4?s record did not obtain a signed resident rights statement. LI requested updated resident rights. Staff 5 stated that they have not been completing resident rights for everyone.
Plan of Correction:	The Resident Care Director (RCD) audited resident files for annual review of resident rights signed by the resident or responsible party. Assisted Living Coordinator (ALC) / Reminiscence Coordinator (RC) were re-educated on process for annual review of resident rights to include resident or responsible party signature. The ED or designee will complete quarterly audits of resident files to verify compliance (QAPI meeting). 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 #:	22VAC40-73-950-E
Description:	Based on record review and staff interview, facility failed to implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review shall be documented by signing and dating. Evidence: 1. LI requested semi-annual review documentation. 2. Staff 1 stated she does not have any documentation and had not known of this required review.
Plan of Correction:	Maintenance Coordinator (MC) and Area Facilities Manager (AFM) reviewed and updated Emergency Preparedness binder and procedures. Area Facilities Manager completed re-education with MC or designee on the Emergency Preparedness process. MC or designee will audit staff, resident, and volunteer compliance quarterly during QAPI meeting to verify compliance. 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 #:	22VAC40-73-950-F
Description:	22VAC40-73-950-F Based on record review and staff interview, facility failed to review the emergency preparedness plan annually or more often as needed, document the review by signing and dating the plan, and make necessary plan revisions. Such revisions shall be communicated to staff, residents, and volunteers. Evidence: 1. LI requested updated documentation of the annual review of emergency preparedness. The last dated update was in 2018 and 2017. 2. Staff 1 stated that the facility does not have any documentation for the years after 2018 of any emergency preparedness plan review for staff or residents.
Plan of Correction:	Emergency Preparedness binder was audited and updated with phone numbers for emergency situations to include disaster preparedness. MC or designee will review Emergency Preparedness (EP) resource binder with staff, residents, and volunteers semi-annually and document review. ED and MC or designee will review the emergency preparedness plan annually, make any necessary revisions, and document the review by signing and dating the plan. 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 #:	22VAC40-73-980-A
Description:	Based on observation and staff interview, the facility failed to ensure a complete first aid kit is on hand. Evidence: 1. First aid kit on hand did not include: Antiseptic wipes or ointment, any assorted band aids, only 1 triangular bandage for entire facility. 2. Staff 1 stated that she did not know that additional items were needed for first aid kit on hand.
Plan of Correction:	RCD audited first aid kits in designated locations for accuracy according to the list of first aid requirements. RCD was re-educated on regulatory requirements regarding first aid kits in the facility. RCD or designee will complete monthly audit for 3 months. Any discrepancies identified will be rectified. 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 #:	22VAC40-73-980-C
Description:	Based on record review and staff interview, facility failed to ensure month first aid kits are checked at least monthly to ensure all items are present. Evidence: 1. LI requested evidence of monthly check of first aid kit. 2. Staff 1 stated that facility does not have any evidence that facility has been completing a monthly check.
Plan of Correction:	RCD audited first aid kits in designated locations for accuracy according to the list of first aid requirements. RCD was re-educated on regulatory requirements regarding first aid kits in the facility. RCD or designee will complete monthly audit for 3 months. Any discrepancies identified will be rectified. 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.