VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise of Falls Church
330 North Washington Street
Falls church, VA 22046
(703) 534-2700

Current Inspector: Marshall Massenberg (804) 543-5188

Inspection Date: Aug. 31, 2021 and Sept. 3, 2021

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 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:

A monitoring inspection was initiated on 8/31/2021 and concluded on 9/3/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 49. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed three resident records, three staff records, annual fire and health inspection reports, dietary and healthcare oversight reports, staff work schedule, activity calendar, monthly menu submitted by the facility to ensure documentation was completed. Criminal Background Checks of all staff hired since the previous inspection conducted on 2/18/2021 were reviewed. The inspector conducted the on-site inspection on 9/2/2021. An exit interview was conducted with the administrator on 9/3/2021 where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility. 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 standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-C
Description:	Based upon a review of records and interview, the facility failed to ensure that medications shall be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: According to the Medication Administration Record (MAR) and the Location of Administration Report, on 8/24/2021 the 8 am dosage of Resident #2's Rivastigmine Patch and the 8 am dosage of Resident #2's Insulin Aspart Solution was administered at approximately 10:24 am. An interview with Staff #4 confirmed that the above listed medications were administered at approximately 10:24 am, 2 hours and 24 minutes past the schedule dosing time of 8 am.
Plan of Correction:	A. With respect to the specific resident cited: Resident # 2 experienced no negative outcomes as a result of not administering within the standard during schedule. PCP was notified of late administration and no adverse reaction being noted. The Resident Care Director conducted refresher training with the specific medication care manager regarding the importance of and process for adhering to medication administration timeframes. B. With respect to how the facility will identify residents with the potential for the identified concerns: The Resident Care Director is conducting unannounced medication administration pass observations to confirm that medications are administered within the correct time frame.Issues that may be identified will be addressed and resolved and refresher training initiated as needed. C. With respect to what systemic measures have been put into place to address the stated concern: The Resident Care Director will conduct refresher training with the medication care managers and nurses regarding the process for administering medications within the appropriate time frame. D. With respect to how the plan of correction will be monitored: The Resident Care Director or designee will continue to conduct unannounced medication pass observations weekly for 3 months to confirm medications are given within the correct time frame as well as a review will take place during the morning community meeting to identify any med pass discrepancies from the previous day. Issues that may be identified will be addressed and resolved and refresher training initiated as needed.The Resident Care Director or designee will present the results of the medication-pass observations to the Quality Assurance and Performance Improvement Committee (QAPI) committee monthly for three months. During and at the end of 3 months, the QAPI committee will evaluate the results and determine if additional focus or action is warranted. The Executive Director or designee is responsible for confirming implementation and ongoing compliance components of this Plan of Correction and addressing and resolving variances that may occur.