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: Oct. 25, 2021 and Oct. 29, 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.

Technical Assistance:

A completed Renewal Application must be submitted prior to the expiration of the current license. The facility should receive an application in the mail, however if an application has not been received one can be obtained from the DSS web site or by calling the main office at (276) 206-0492.

Comments:

A renewal inspection was initiated on 10/25/2021 and concluded on 10/29/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 48. 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, activity calendar, monthly menu, fire drill reports, healthcare and dietary oversight reports, annual health and fire inspection reports submitted by the facility to ensure documentation was complete. Criminal Background Checks of all staff hired since the previous inspection conducted on 9/3/2021, were reviewed. The inspector conducted the on-site portion of the inspection on 10/28/2021. An exit interview, was conducted with the Administrator on 10/29/2021, 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-D
Description:	Based upon a review of records, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. According to the physician's order written 6/30/2021, Resident #3 is to receive Senna-Docusate Sodium Tablet 8.6-50mg, 2 tablets every 24 hours as needed for bowel regimen, if not effective, may offer PRN (as needed) Miralax. The Medication Administration Record (MAR) for 10/15/2021 indicates that Resident #3 was administered Senna-Docusate Sodium Tablet at approximately 11:32 am and on 10/16/2021 the medication was administered at approximately 7:53 am, which is 20 hours and 22 minutes after the previous dosage was administered. . The MAR documents that on 10/21/2021, Resident #3 was administered a dosage of Senna Docusate Sodium Tablet at approximately 19:04 (7:04 pm) and again at approximately 7:54 am, which is 12 hours and 54 minutes after the previous dosage was administered.
Plan of Correction:	Resident #3 experienced no negative outcomes as a result of medication administration on 10/15/2021 and 10/21/2021. The Resident Care Director (RCD) conducted a refresher training with medication care manager regarding the importance of and process for adhering to medication administration in accordance with the physician's orders. The RCD conducted unannounced medication pass observations of medication care managers to confirm medications are being administered in accordance with physician orders. Any concerns identified are addressed, resolved and a refresher training provided as needed. The RCD conducted refresher training with the specific medication care manager regarding the importance of and process for adhering to medication administration in accordance with the physician's orders and to report issues with order clarification to the RCD so that they can be addressed timely by the clinical team, pharmacy, and physician. The Wellness Nurses and Med Care Managers (MCMs) were re-educated by the RCD regarding the process to confirm medications prior to administration and to report issues with order clarification to the RCD so that they can be addressed timely by the clinical team, pharmacy, and physician. The RCD or wellness designee conducts weekly audits for 1 month, and monthly audits for 2 months, to confirm accuracy between physician orders, and the EMAR. Issues that may be identified will be addressed and resolved and refresher training initiated as needed. The results of the audits will be presented by the RCD or wellness designee at Quality Assurance and Performance Improvement (QAPI) meeting for 3 months. During and at the end of 3 months, the QAPI Committee will evaluate the results of the medication care audits and determine if additional focus or action is warranted. The Executive Director (ED) 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.