VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise of Fairfax
9207 Arlington Boulevard
Fairfax, VA 22031
(703) 691-0046

Current Inspector: Marshall Massenberg (804) 543-5188

Inspection Date: Feb. 9, 2023

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. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Technical Assistance:

A completed Renewal Application must be submitted prior to the expiration of the current license. An application can be obtained from the DSS website. Please mail the application and payment to VDSS ? Western Licensing Office, 190 Patton Street, Suite 100, Abingdon, VA 24210 ? ATTN: Application Processing. Please update the posted resident rights to reflect the current Licensing Administrator ? Sharae Henderson, 804-629-3479

Comments:

An unannounced renewal inspection was conducted on 2/9/2023. At the time of entrance 40 residents were in care. The sample size consisted of seven resident records, four staff records and three individual interviews. Resident and staff records and other documentation were reviewed. Virginia State Police background checks reviewed for all new staff hired since the previous inspection conducted on 3/9/2022. Residents were observed eating breakfast and lunch and engaging in activities including current events and guest piano entertainer. Medication administration was observed. An exit meeting was 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. 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 within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. 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 the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lynette Storr, Licensing Inspector at (703) 479-4708 or by email at lynette.storr@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-440-A
Description:	Based on interview and documentation review facility failed to ensure that the UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition. Evidence: Resident #5?s most recent UAI dated 11/10/2022 assesses the resident as appropriate in behavior patterns. On 12/23/2022 and 1/10/2023 the resident exhibited wandering behavior.
Plan of Correction:	Resident #5 did not have any negative outcomes as a result of behavior patterns not on the UAI. The UAI was updated to reflect the behaviors. Resident Care Director and Assisted Living Coordinator (RCD/ALC) conducted an audit to confirm that residents with behavior patterns have updated behavior pattern on the UAI. The RDC completed training with the Wellness Nurses, the ALC on UAI requirements and compliance. The RCD or designee will continue to conduct UAI audit weekly for 3 months to confirm that the UAI is appropriately identified on residents with behavior patterns. Issues identified will be addressed and resolved. During and at the end of the 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 (ED) 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 addressing and resolving variances that may occur.
Standard #:	22VAC40-73-450-F
Description:	Based on interview and documentation review facility failed to ensure that Individualized Service Plans (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: Resident #4?s most recent ISP does not reflect the resident?s current assessed need for CCHO diet (ordered 9/7/2022) and assistance with medication.
Plan of Correction:	Resident #4 did not have any negative outcomes as a result of a CCHO diet and assistance with medication not on the ISP. The ISP was updated to reflect the CCHO diet and assistance with medication. RCD/ALC conducted an audit to confirm that residents with special diets and assistance with medication are updated on ISP. The RCD completed training with the Wellness Nurses, and the ALC on ISP requirements and compliance. The RCD or designee will continue to conduct ISP audit weekly for 3 months to confirm that the ISP is appropriately updated with special diets and assistance with medications. Issues identified will be addressed and resolved. During and at the end of the 3 months, the QAPI committee will evaluate the results of the audits and determine if additional focus or action is warranted. The ED 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 #:	22VAC40-73-460-D
Description:	Based on interview and documentation review facility failed to ensure supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises. Evidence: On 12/17/2022 Resident #1 exited the safe secure environment unsupervised and was found in the assisted living area of the facility. On 12/23/2022 and 1/10/2023 Resident #5 exited the safe secure environment unsupervised and was found in the assisted living area of the facility.
Plan of Correction:	Resident #1 was immediately located outside exit doors and within the assisted living area and returned to the secured unit by a staff person. The resident was assessed and found to have no injury or other clinical concerns. Resident #5 was immediately located outside exit doors and within the assisted living area and returned to the secured unit by a staff person. The resident was assessed and found to have no injury or other clinical concerns. Maintenance Coordinator (MC) secured exit doors from the secured neighborhood and verified the magnetic locks were operational. Facility immediately implemented changing of codes on all exit/entry doors of secure neighborhood; staff were retrained; and new procedure implemented whereby code known only by staff. Elevator vendor reprogrammed elevator resulting in movement only with a facility-issued fob. The MC or designees continue to conduct monthly elopement drills. The MC or designee performs an audit of all doors following any fire drill, during which magnetic locking mechanism becomes disabled to allow for egress in the event of an emergency. The results of the elopement drills and audits will be presented by the MC or designee at QAPI for 3 months. During and at the end of the 3 months, the QAPI Committee will evaluate the results of the elopement drills and audits, and determine if additional focus or action is warranted. The ED 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 #:	22VAC40-73-480-E
Description:	Based on interview and documentation review facility failed to ensure that the services provided, evaluations of progress, and other pertinent information regarding the rehabilitative services shall be recorded in the resident's record. Evidence: Resident #2 received physical and occupational therapy between 10/20/2022 ? 11/30/2022 and Resident #6 received physical and occupational therapy between 12/12/2022 ? 2/2/2023. The notes in the resident record did not reflect specific services provided or evaluations of progress.
Plan of Correction:	Resident #2 record was updated with the specific physical and occupational notes. Resident #6 record updated was updated with the applicable evaluations and specific physical and occupational notes. RCD conducted an audit of residents receiving rehab services and updated any records needed to reflect the services provided, evaluations of progress, and other pertinent regarding the rehabilitative services. RCD completed training with the therapists on the recording of rehabilitative service requirements and compliance. The RCD or designee will continue to conduct rehab service documentation audits weekly for 3 months to confirm that the record is reflective of the services provided, evaluations of progress, and other pertinent information regarding the rehabilitative services shall be recorded. During and at the end of the 3 months, the QAPI committee will evaluate the results of the audits and determine if additional focus or action is warranted. The ED 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.