11
Inspections
On record
9
With violations
Visits that cited something
2
Clean visits
Nothing cited
22
Violations cited
Individual findings
18
Standards cited
Distinct rules
1
Complaint visits
Prompted by a complaint
Sunrise at Hunter Mill was inspected 11 times between November 13, 2020 and May 7, 2026 by the Virginia Department of Social Services. 9 of those visits ended with violations cited and 2 with none. Across that history VDSS cited 22 violations under 18 distinct standards. 1 inspection was prompted by a complaint.
A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.
VDSS publishes inspections on a rolling window. 10 of these 11 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.
Provider Information
Facility type
Assisted Living Facility
License type
One Year
License expires
12/09/2026
Administrator
Isha Subedi
Licensing inspector
Alexandra Roberts
Inspector phone
(804) 845-6956
Approved for
Non-Ambulatory · Assisted Living · Special Care Unit
Inspection History
11Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.
May 7, 2026Inspection
Inspection dates
05/07/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
22VAC40-73-290-B
Comments
Type of inspection: Monitoring
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/07/2026 9am - 11am
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: 72
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Observations by licensing inspector: LI observed residents in engaging with one another and partaking in scheduled activities.
Additional Comments/Discussion: None
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary.
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 Alexandra Roberts, Licensing Inspector at (804) 845-6956 or by email at Alexandra.n.roberts@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
November 20, 2025Inspection
Inspection dates
11/20/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS63.2 GENERAL PROVISIONS63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
Ensure that during the hiring process to create new records for staff.
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: 11/20/2025 9:30am – 4pm
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: 80
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 6
Number of staff records reviewed: 4
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 3
Observations by licensing inspector: Observed residents engaging with each other in the common area and eating lunch in the dining hall.
Additional Comments/Discussion: None
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.
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 Alexandra Roberts, Licensing Inspector at (804) 845-6956 or by email at Alexandra.N.Roberts@dss.virginia.gov
Violations
22VAC40-73-860-D
Based on observation and interview, the facility failed to ensure that any operable window shall be effectively screened.
Evidence
- During facility tour on 11/20/2025, Two licensing staff observed two second floor resident rooms did not have screens.
- Staff confirmed the missing window screens with licensing staff outside of the facility.
Plan of correction
A.) With respect to the specific resident/situation cited:
The Maintenance coordinator replaced identified windows
without proper screening. There were no negative outcomes.
8.) With respect to how the facility will identify
residents/situations with the potential for the identified
concerns:
Maintenance coordinator performed a facility wide audit of
operable windows to identify any additional missing screens.
Windows identified with missing screens were replaced.
C.) With respect to what systemic measures have been
put into place to address the stated concern:
Maintenance coordinator and or designee to inspect operable
windows monthly for 2 months to confirm proper screening is
in place. Any inconsistencies identified will be corrected.
D.) With respect to how the plan of correction will be
monitored:
The Executive Director, or designee is responsible for
implementation and ongoing compliance with the components
of this Plan of Correction and addressing and resolving
variances that may occur.
22VAC40-73-650-A
Based on record review and interview, the facility failed to ensure that no medication, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber.
Evidence
- Resident 3’s record contained an oral order taken on 10/30/2025 for “Wound care – Stage 4 sacrum pressure injury….”. The order was not signed as of date of inspection on 11/20/2025.
- Staff 4 confirmed that Resident 3 has been obtaining wound care services for the Stage 4 wound.
- Licensing staff did not observe a valid order from a physician or other prescriber for Resident 3’s wound care treatment as of 11/20/2025.
Plan of correction
A.) With respect to the specific resident/situation cited:
Physicians order for Resident #3 was reviewed and signed by
provider.
B.) With respect to how the facility will identify
residents/situations with the potential for the identified
concerns:
Resident Care Director will conduct an audit of current
residents records to verify residents have a valid signed order
for medications and treatments.
The Resident care Director (RCD) conducted refresher
training with the wellness nurses regarding the importance of
needing a valid signed order and to report issues with orders to
the resident care director so that they can be addressed timely
by the clinical team, pharmacy and physician.
C.) With respect to what systemic measures have been
put into place to address the stated concern:
The Resident Care Director or Designee will continue to audit
physician orders for 2 months to confirm orders are present in
the resident's electronic health record. Issues that may be
identified will be addressed and resolved and refresher training
indicated as needed.
Results of the order audits will be presented to the Quality
assurance and Improvement Committee monthly for 2 months.
During and at the end of2 months, the (QAPI) committee will
evaluate the results and determine if additional focus or action
is warranted.
D.) With respect to how the plan of correction will be
monitored:
The Executive Director, or designee is responsible for
implementation and ongoing compliance with the components
of this Plan of Correction and addressing and resolving
variances that may occur.
22VAC40-73-450-D
Based on record review and interview, the facility failed to ensure that when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan.
Evidence
- Resident 3 began receiving hospice services on 09/03/2024 per hospice documentation. Resident 3’s ISP dated 07/28/2025 did not include hospices services that are being provided by each party.
- Resident 4’s physician order to admit to hospice for wound care was dated 10/03/2025. Resident 4’s ISP dated 07/08/2025 with an indication that the ISP had a revision on 10/15/2025 did not include hospice services that are being provided by each party.
- Staff 2 and Staff 4 acknowledged Resident 3 and Resident 4’s ISPs did not contain the specific services provided by the facility and the licensed hospice organization in the plan.
Plan of correction
A.) With respect to the specific resident/situation cited:
Residents #3 and #4 had no negative outcome and both ISP
updated to include hospice services being provided.
B.) With respect to how the facility will identify
residents/situations with the potential for the identified
concerns:
Resident Care Director (RCD) and or designee conducted an
audit of current residents receiving Hospice services to
ensure ISP's reflects hospice involvement and services
provided by both parties.
Executive Director conducted a refresher training with the
wellness team regarding on Hospice collaboration
requirements.
C.) With respect to what systemic measures have been
put into place to address the stated concern:
The Resident Care Director and or Designee will monitor
residents on hospice services weekly for the next 2 months to
ensure services provided are included on the ISP. Issues
identified will be resolved and taken to Quality Assurance and
Performance Improvement.
D.) With respect to how the plan of correction will be
monitored:
The Executive Director, or designee is responsible for
implementation and ongoing compliance with the components
of this Plan of Correction and addressing and resolving
variances that may occur.
22VAC40-73-650-C
Based on record review and interview, the facility failed to ensure that physician's or other prescriber's oral orders be reviewed and signed by a physician or other prescriber within 14 days.
Evidence
- Resident 1’s record contained oral order taken on 05/20/2025 for Morphine 20mg Q4 hours PRN that was not signed by a physician as of date of inspection on 11/20/2025.
- Resident 3’s record contained the following oral orders that were not signed as of date of inspection on 11/20/2025: - 10/30/2025 for “Wound care – Stage 4 sacrum pressure injury….”. - 10/29/2025 to DC “Morphine ER 15mg…” and to start “Oxycodone 10mg...” - 10/23/2025 oral order to DC “morphine 100mg PRN…” and “Oxycodone 10mg tablet PRN…” - 10/23/2025 oral order to “Edit/Start - Oxycodone 325mg tablet…” - 10/21/2025 oral order to DC “metoprolol ER 25mg…” and to Start “Morphine ER 15mg…” - 10/18/2025 oral order to start “2-guard BID…” and “Morphine 20mg…” - 08/19/2025 for detailed wound care cleansing orders. - 08/14/2025 for detailed wound care cleansing orders.
- Staff 2 and Staff 4 acknowledged the unsigned oral orders in Resident 1 and 3’s record.
Plan of correction
A.) With respect to the specific resident/situation cited:
Resident #1 experienced no negative outcome as a result of
unsigned order. A valid signed order received from the
provider
B.) With respect to how the facility will identify
residents/situations with the potential for the identified
concerns:
Resident Care Director will conduct an audit of current
residents record to verify verbal orders are signed within 14
days of being taken.
The Resident care Director (RCD) conducted refresher
training with the wellness nurses regarding the process of
obtaining a signature from a physician on a verbal order within
the appropriate timeframe.
C.) With respect to what systemic measures have been
put into place to address the stated concern:
The Resident Care Director or Designee will continue to audit
verbal physician orders for 2 months to confirm signatures are
received within a correct timeframe. Issues that may be
identified will be addressed and resolved and refresher
training indicated as needed.
Results of the verbal order audits will be presented to the
Quality assurance and Improvement Committee monthly for 2
months. During and at the end of 2 months, the (QAPI)
committee will evaluate the results and determine if additional
focus or action is warranted.
D.) With respect to how the plan of correction will be
monitored:
The Executive Director, or designee is responsible for
implementation and ongoing compliance with the components
of this Plan of Correction and addressing and resolving
variances that may occur.
22VAC40-73-310-H
Based on record review and interview, the facility failed to ensure that in accordance with § 63.2-1805 D of the Code of Virginia, assisted living facilities
shall not admit or retain individuals with Dermal ulcers III and IV except those stage III ulcers that are determined by an independent physician to be healing.
Evidence
- During inspection on 11/20/2025, Resident 3’s medical record contained an unsigned physician order stating, “Wound care – Stage 4 sacrum pressure injury”. Additionally, Residents 3’s ISP dated 07/08/2025 with a revision date of 10/15/2025 indicated having “Stage 4 pressure ulcer on coccyx”.
- Staff 2 to provided list of additional residents with wounds which included Resident 4’s medical documentation titled “IDG Meeting Review” dated 10/15/2025 (electronically signed by physician, nurse practicer, Chaplin and Social worker for the resident) assessment indicating that Resident 4 has a “Stage 4 pressure ulcer to right hip and buttocks and left inner new, and unstageable to left heel are getting worse, requiring wound care days increased to three times a day, Also continue to manage wounds and foul odor….”
- During inspection on 11/20/2025, Resident 5’s medical documentation from 11/12/2025 visit indicates having a “Stage 3 Pressure injury acquired on 10/07/2025…” and further stated that Resident 5’s wound has worsened with a new areas of DTI.
- Staff 2 and Staff 4 both confirmed Resident 3 and Resident 4 both have Stage 4 wounds and are presently still retained as residents at the facility.
Plan of correction
A.) With respect to the specific resident/situation cited:
Residents #3,4,5 experienced no negative outcome, as a result
of their pressure ulcers and were safely discharged to
appropriate settings.
B.) With respect to how the facility will identify
residents/situations with the potential for the identified
concerns: RCD conducted skin checks on current residents to ensure no
additional pressure injury exists, Weekly Interdisciplinary teams (IDT) meetings will be
conducted to proactively identify and address early signs of
pressure injuries for the next 60 days. Issues identified will be
addressed.
C.) With respect to what systemic measures have been
put into place to address the stated concern:
Resident Care Director or Designee will continue to conduct
the weekly skin checks on residents identified at risk for pressure injuries and consult with an independent physician if
pressure injury greater than Stage II. Executive Director (ED) re-educated the wellness team on the
prohibitive conditions surrounding admission or retention of residents with wounds greater than stage 2.
D.) With respect to how the plan of correction will be monitored:
The Executive Director, or designee is responsible
for implementation and ongoing compliance with the
components of this Plan of Correction and addressing and
resolving variances that may occur.
22VAC40-73-530-B
Based on observation and interview, the facility failed to ensure that doors leading to the outside shall not be locked from the inside or secured from the inside in any manner that amounts to a lock.
Evidence
- During inspection on 11/20/2025, two licensing inspectors observed first floor door leading to an outside sitting patio area to be locked with keypad and code from the inside. From the outside of the door, two licensing staff observed that the door was locked from the outside leading back into the facility requiring a code as well. The door was not within the safe, secure environment.
- During inspection on 11/20/2025, two licensing inspectors observed two first floor doors within the activity room leading to an outside front porch sitting area to be locked. The two doors observed were not within the safe, secure environment.
- Staff 4 confirmed that the doors are locked and require code to enter and exit.
Plan of correction
A.) With respect to the specific resident/situation cited:
No negative outcome to the Residents as a result of keypads
on doors. The keypads requiring a code from either side are in
the process of being disabled and reprogramed to ensure that
residents can enter and exit freely without interference.
B.) With respect to how the facility will identify
residents/situations with the potential for the identified
concerns:
Any future work orders involving doors or locks will
automatically trigger administrative review to ensure
regulatory compliance before installation or reactivation.
The ED and the Maintenance director reviewed the master
key, key pad and alarm systems to identify any devices that
may unintentionally require a key, code, or impediment from
the inside.
C.) With respect to what systemic measures have been
put into place to address the stated concern:
A new Door safety & Egress Compliance Policy has been
initiated outlining that exterior doors accessible to residents
must allow free egress without the use of the key or code.
The Maintenance Director will conduct weekly door checks for
next 30 days. Issues identified will be resolved and taken to
Quality Assurance and Performance Improvement.
D.) With respect to how the plan of correction will be
monitored:
The Executive Director, or designee is responsible for
implementation and ongoing compliance with the components
of this Plan of Correction and addressing and resolving
variances that may occur.
November 25, 2024Inspection
Inspection dates
11/25/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICESNone
Comments
Type of inspection: ¿Monitoring¿
Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/25/2024,10:45am-1:00pm
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-report was received by VDSS Division of Licensing on 11/03/2024 regarding allegations in the area(s) of: Resident health and medication(s).
Number of residents present at the facility at the beginning of the inspection: 71
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of interviews conducted with residents:0
Number of interviews conducted with staff: 2
Observations by licensing inspector: Exercise and lunch.
Additional Comments/Discussion: Interview with POA of the resident.
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did NOT support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary.
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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Type of inspection: ¿Monitoring¿
Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/25/2024,10:45am-1:00pm
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-report was received by VDSS Division of Licensing on 11/03/2024 regarding allegations in the area(s) of: Resident health and medication(s).
Number of residents present at the facility at the beginning of the inspection: 71
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of interviews conducted with residents:0
Number of interviews conducted with staff: 2
Observations by licensing inspector: Exercise and lunch.
Additional Comments/Discussion: Interview with POA of the resident.
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did NOT support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary.
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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violation Notice Issued: ¿No¿
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
September 19, 2024Inspection
Inspection dates
9/19/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 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: 09/19/2024 9am - 3:30pm
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: 75
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 3
Observations by licensing inspector: LI observed a medication pass. LI observed residents eating lunch and dinner, entering and exiting the facility for community outings and residents interacting with staff.
Additional Comments/Discussion: N/A
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 Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.N.Roberts@dss.virginia.gov
Violations
22VAC40-73-660-A-1
Based on observation, the facility failed to ensure that a medicine cabinet, container, or compartment shall be used for storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility. Medications shall be stored in a manner consistent with current standards of practice.
Evidence
- LI also observed Lidocaine 4% patches prescribed to Resident 4 unsecured on top of the cart.
- Facility staff down the hall informed LI that staff 2 was currently in a resident 4’s room administering medications at the time of observation.
- LI obtained photo evidence.
Plan of correction
A. immediate Solution: With respect to the specific resident/situation cited
Resident #4 did not experience any negative outcome because of empty resident medication package with the identifier left on top of the cart.
B. Expand Scope: With respect to how the facility will identify residents/situations for the identified concerns:
RCD or Designee conducted a refresher training with medication care managers and nurses on secure storage of medication cart as standard of practice.
RCD or designee conducted a refresher training with the medication managers and wellness nurses on destructions of empty resident identifiers after use of medication per standard
C.Systemic Change: With respect to what systemic measures have been put into place to address the stated concern:
The Resident Care Director or designee will continue to conduct weekly audits for 3 months to confirm medications are securely locked in the medication cart and empty medication boxes with resident identifiers
are destroyed per policy.
D. Monitoring: With respect to how the plan of correction will be monitored
During and at the end of the 3 months, the QAPI Committee
will evaluate the results and determine if additional focus or
action is wan·anted.
The Executive Director, RCD 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
22VAC40-73-490-D
Based on record review, the facility failed to ensure that the specific residents for whom the health care oversight was provided were identified.
Evidence
- Healthcare oversight documents dated 6/25/2024 did not identify the residents reviewed during oversight period.
- During interview on 09/19/2024, staff 4 confirmed the 06/25/2024 health care oversight report did not specify the residents included the oversight period.
Plan of correction
A. Immediate Solution: With respect to the specific resident/situation cited
No negative outcomes were noticed due to missing identified during oversight period.
B. Expand Scope: With respect to how the facility will identify residents/situations for the identified concerns:
RCD or designee captured all the resident's information who were seen during the oversight period and updated the report.
C. Systemic Change: With respect to what systemic measures have been put into place to address the stated concern:
RCD or Designee to document and specify resident reviewed during the oversight period in the body of the report.
D. Monitoring: With respect to how the plan of correction will be monitored
During and at the end of the 3 months, the QAPI Committee will evaluate the results and determine if additional focus or action is warranted.
22VAC40-73-950-E
Based on record review and staff interview, the facility failed to ensure semi-annual review on the emergency preparedness and response plan for all staff and residents. The review shall be documented by signing and dating.
Evidence
- LI requested documented Emergency preparedness semi-annual review. Staff 4 provided a ‘midnight census’ dated 6/28/2024 with “semi-annual review” hand-written at the top.
- Staff 4 confirmed that the review dated 06/28/2024 did not contain signatures or dates.
- LI obtained photo evidence
Plan of correction
A. immediate Solution: With respect to the specific resident/situation cited
No negative outcomes were noticed due to missing residents
& staffs signature and date during the semiannual emergency
preparedness and response plan.
B. Expand Scope: With respect to how the facility will identify residents/situations for the identified
concerns:
Maintenance coordinator or designee will ensure residents
and team members signature are physically obtained in real
time in the drill form once its completed.
C.Systemic Change: With respect to what systemic
measures have been put into place to address the
stated concern:
Maintenance coordinator or designee to print the drill signup
sheet for residents & team members before the drill.
Physical signature to be obtained in the real time once the
drill is completed.
D. Monitoring: With respect to how the plan of
correction will be monitored
During and at the end of the 3 months, the QAPI Committee
will evaluate the results and determine if additional focus or action is warranted.
The Executive Director, RCD 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
The MC 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.
December 7, 2023Inspection
Inspection dates
12/07/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 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: 12/7/23 (8:50 AM - 5:10 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: 67
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. An exit meeting was held.
Number of resident records reviewed: 10
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 2
Observations by licensing inspector: Meals, medication administration, activities
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
22VAC40-73-680-I
Based on record review, the facility failed to ensure that all information is documented on the Medication Administration Record (MAR).
Evidence
- Resident #11’s MARs were observed during the inspection. Resident #11’s record contained an order for Metoprolol, dated 9/21/22, that calls for the medication to be held if the resident’s systolic blood pressure (SBP) is less than 100 and heart rate (HR) is less than 60. Resident #11’s MAR states that her Metoprolol was held on 11/15/23, 11/18/23, 11/22/23, 11/24/23, and 12/2/23 due to her vitals being outside of the parameters. Resident #11’s MAR did not contain the resident’s vitals for 11/15/23, 11/18/23, 11/22/23, 11/24/23, and 12/2/23. No documentation was provided, during the inspection, to identify what Resident #11’s vitals were on these dates.
Plan of correction
Resident #11 did not experience any negative outcome as a result of missed documentation.
The Resident Care Director conducted audit to confirm proper documentation per physician's order.
Refresher training with medication care managers and nurses was conducted by the Resident Care Coordinator regarding proper documentation per physician's order.
The Resident Care Director or designee will continue to conduct documentation audits weekly for 3 months to confirm proper documentation per physician's order.
During and at the end of the 3 months, the QAPI Committee will evaluate the results and determine if additional focus or action is warranted.
The Executive Director, RCD 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.
22VAC40-73-450-F
Based on observation and record review, the facility failed to ensure that the individualized service plan (ISP) is reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
- Resident #1’s record was reviewed during the inspection. Resident #1’s ISP, dated 9/8/23, states that the resident receives hospice services, does not walk, and uses a hoyer lift for transfers. Progress notes, included in Resident #1’s record, indicate that he was walking independently on 10/27/23 and that he was discharged from hospice on 11/4/23. During the inspection, Resident #1 was observed walking and transferring without a hoyer lift.
Plan of correction
Resident #1's ISP was updated to reflect current functional status.
The Resident Care Director (RCD) or designee completed an audit of current residents' ISPs to verify compliance with current resident condition. ISPs updated as needed.
The RCD completed training with the Wellness Nurses, Care Coordinators on ISP requirements and compliance
The RCD/Designee will conduct weekly audits for three months to verify ISPs compliance and report outcome to QAPI committee.
During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the ED 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 to correct any deficient practices.
During and at the end of the three months, the QAPI Committee will evaluate the results and determine if additional focus or action is warranted.
The Executive Director, RCD 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.
June 15, 2023Inspection
Inspection dates
06/15/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
An unannounced monitoring inspection was conducted on 6/15/23. At the time of entrance, 67 residents were in care. Meals, medication administration, and activities were observed. Building and grounds were inspected. Records were reviewed. The sample size consisted of 10 resident records and five staff records. The violation was discussed and an exit meeting was held.
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.
Changed to monitoring inspection upon administrative review
Violations
22VAC40-73-680-D
Based on observation and documentation, the facility failed to ensure that medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
- The morning medication administration, for Resident #8, was observed during the inspection. Resident #8's medications were removed from their medication packages, and placed in a pill sleeve to be crushed. Resident #8's medications were crushed and administered in yogurt. Protonix, ordered 9/21/22, was one of the medications that was crushed and administered. The Protonix medication package states that the medication should not be crushed.
Plan of correction
Upon receiving the medication RCD or Wellness Nurse need to check them in and make sure they are on the MAR, at that time they should verify the package instructions and the MAR instruction.
RCD reviewed all the residents with Protonix orders and updated the administrator notes in e-MAR reflecting Do not crush medication.
MCM to double check when passing medications. The Resident Care Director will continue to conduct weekly MAR to cart audits for the next three months, so they can catch anything that was done incorrectly.
The POC will be reviewed for the next three months during the Quality Assurance and Performance Improvement meeting to verify that it is effective. The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
February 27, 2023Inspection
Inspection dates
02/27/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUNDS
Comments
An unannounced focused-monitoring inspection was conducted on 2/27/23 to follow-up on high-risk violations that were cited on 12/2/22. Medication administration and resident records were observed. Building and grounds were inspected.
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
22VAC40-73-650-B
Based on record review, the facility failed to ensure that physician or other prescriber orders, both written and oral, include the strength of each medication and supplement.
Evidence
- The morning medication administration, for Resident #2, was observed during the inspection. Resident #2’s order, for Vitamin D2, did not include the strength of the supplement.
Plan of correction
Resident #2's e-MAR was updated to include the strength of the supplement. The RCD verified all medications on the resident e-MAR indicate include the strength.
The Resident Care Director conducted an audit of e-MARs to verify that prescribed medications include the strength.
The Resident Care Director re-educated wellness nurses on proper transcription of orders in e-Mar to include the strength for each medication prescribed.
The Resident Care Director or designee conducts monthly e-mar to cart audits to verify that prescribed medications include the strength on the order.
The POC will be reviewed for the next 3 months during the Quality Assurance and Performance Improvement meeting to verify that it is effective.
The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-680-D
Based on record review, the facility failed to ensure that medications are administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
- The morning medication administration was observed, for Resident #1, during the inspection. Resident #1’s Synthroid was administered at approximately 8:27 AM. The medication package stated that it should be given on an empty stomach. At approximately 8:50 AM, Resident #1 was observed eating breakfast. Resident #1’s Synthroid was not administered at least one-half to one hour before eating breakfast.
Plan of correction
Resident #1 was evaluated by the Resident Care Director; the resident did not experience any negative outcomes.
The Resident Care Director conducted an audit for residents prescribed Synthroid, to verify that the medication is scheduled on the e-MAR and medication label to be administered per Physician orders. Any issues identified were resolved.
The Resident Care Director conducted a refresher training with the wellness nurses on order verification and transcribing into the e-Mar upon the orders being received. Any concerns identified during the process to be addressed with the provider immediately.
The POC will be reviewed for the next 3 months during the Quality Assurance and Performance Improvement meeting to verify that it is effective.
The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
December 2, 2022Inspection
Inspection dates
12/02/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/2/22 (8:01 AM – 11:50 AM)
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
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.
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 Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov
Violations
22VAC40-73-530-B
Based observation, the facility failed to ensure that doors leading to the outside are not locked from the inside or secured from the inside in any manner that amounts to a lock, except that doors may be locked or secured in a manner that amounts to a lock in special care units as provided in 22VAC40-73-1150 A. Any devices used to lock or secure doors in any manner must be in accordance with applicable building and fire codes.
Evidence
- Upon the licensing inspector’s arrival at the facility at 8:01 AM, the facility’s front door was unable to be opened from outside the building. Shortly after the inspector arrived, a visitor attempted to exit the building using the front door. He pushed on the door, but it would not open. The visitor stated that he was unable to open the door, as he did not have the code for the door. No staff members were present to open the door, and the visitor pushed on the door for 15 seconds, in order for the door’s security to be released. After the door was opened, a staff member was located and informed about the door. Facility staff reported that a staff member was supposed to be present to open the door for visitors. There is a device that would allow the staff member to disengage the door’s security, so that it can be freely opened. The Fairfax Fire Marshal’s office was contacted about the facility’s permit to secure the front doors. The Fire Marshal’s representative reported that their office did not have a permit on file, for the facility to secure doors that lead outside.
Plan of correction
The facility shall provide freedom of movement for all the residents. The facility shall not lock doors leading to the outside of the community and doors shall not be locked from the inside or secured from the inside in any manner.
The Executive Director is working along with the State Code and related department to get the issue resolved as soon as possible. In the meantime, the community leader will ensure that residents in Assisted living will have the freedom to exit/enter building with no restrictions during business hours.
The Executive Director and Maintenance Coordinator will review and will have a front door security that allows for the front door in the community to be opened during normal business hours. Additionally, residents have been notified during the resident council meeting about door being unlocked during normal business hours. Residents were also encouraged to utilize the sign out books for the safety purpose. Families are to be notified of the change in our weekly communication via email.
The leadership team (Executive Director, QAPI Team) will evaluate the results/process to determine if additional focus or action is warranted during Monthly Quality Assurance and Performance Improvement (QAPI) meetings.
During and after 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.
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 to correct any deficient practices.
22VAC40-73-680-D
Based on record review, the facility failed to ensure that medications are administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
- Resident #1’s November MAR (medication administration record) was reviewed during the inspection. Resident #1 receives Eliquis twice per day. The MAR states that Resident #1’s Eliquis wasn’t administered on 11/21/22, 11/22/22, or 11/23/22. Resident #1’s morning administration of Eliquis was also not administered on 11/24/22. The MAR listed Resident #1’s Eliquis as a “medication pending delivery,” on those dates.
Plan of correction
Resident #1 did not experience any negative outcomes as a result of Eliquis not being administered. Medication is available for administration per physician's orders.
The Resident Care Director conducted e-MAR to medication cart audit weekly for 3 months to confirm that medications are available and administered per the physician's order. The Resident Care Director conducted a training with Wellness Nurses and Med techs regarding proper follow ups on pending medication deliveries.
Resident Care Director and Wellness nurse will follow up with pharmacy concerning any pending medications to confirm resident medications are available for administration.
The Resident Care Director or designee will continue to conduct e-MAR to medication carts audits weekly for 3 months to confirm that medications are available and administered per the physician's order.
The results of the audits will be presented by the Resident Care Director and/or wellness designee at Quality Assurance and Performance Improvement (QAPI) meeting for 3 months.
The Resident Care Director will re-evaluate and initiate necessary action or extend the review period if necessary.
The Executive Director or designee 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.
June 27, 2022Inspection
Inspection dates
06/27/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
Documentation was discussed with the provider.
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: 6/27/22 (8:20 AM – 6:45 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: 73
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
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.
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
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 Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-680-D
Based on record review, the facility failed to ensure that medications are administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
- Resident #1’s June MAR (medication administration record) was reviewed during the inspection. Resident #1 receives Amlodipine Besylate at bedtime. Resident #1’s Amlodipine Besylate order, dated 3/9/22, states that the medication should be held when her systolic blood pressure is below 120. Resident #1’s MAR indicated that the medication was administered on 6/4/22, when her systolic blood pressure was 112. The medication was also documented as being administered on 6/11/22, when her systolic blood pressure was 116.
Plan of correction
Resident #1 did not experience any negative outcomes as a result Amlodipine Besylate administered on June 4th & June 11th. Resident's doctor was made aware.
The Resident Care Director or Designee conducted an audit of residents with specific order parameter to verify the medication are administered according to the MD orders.
The Resident Care Director or Designee conducted refresher training with the medication care managers and nurses regarding the process for administering medications according to physician's order.
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 prescribed orders. Issues that may be identified will be addressed.
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 to correct any deficient practices.
22VAC40-73-680-M
Based observation and documentation, the facility failed to ensure that medications ordered for PRN administration are available and properly stored at the facility.
Evidence
- Resident #4’s PRN Famotidine, Midazolam, and Tylenol suspension were not available for administration, at the time of the medication cart inspection. Facility staff confirmed that Resident #4’s PRN Famotidine, Midazolam, and Tylenol were not available for administration, at the time of the medication cart inspection.
Plan of correction
Resident #2 did not experience any negative outcome. PRN medication was ordered & refilled on 6/28. The WN completed an audit of the medication carts to verify PRN medications ordered were available.
The RCD conducted a refresher training with the Medication Care managers on timely refilling process.
The Resident Care Director and designee conducted eMAR & medication cart audit to confirm medications were available per physician's order. The RCD or designee will conduct audits of medication cart on monthly for 3 months to confirm that resident who has PRN orders are available. Issues identified will be resolved.
During and after 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.
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 to correct any deficient practices.
August 10, 2021Complaint survey
Inspection dates
08/10/2021
Areas reviewed
22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS
Comments
A non-mandated complaint inspection was initiated on 8/10/21 and concluded on 10/6/21. A complaint was received by the department regarding allegations in the areas of: Admission, Retention, and Discharge of Residents, Resident Care and Related Services, and Building and Grounds. The administrator was contacted by telephone to conduct the investigation. The licensing inspector conducted an on-site observation at the facility on 8/10/21.
The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-325-C
Based on documentation and interview, the facility failed to document an analysis of the circumstances of falls and interventions that were initiated to prevent or reduce risk of subsequent falls.
Evidence
- The record for Resident #1, admitted 4/22/21, was observed during the inspection. Resident #1's Uniform Assessment Instrument (UAI), dated 4/22/21, states that the resident needs mechanical and physical assistance for walking and mobility. Resident notes indicate that Resident #1 fell on 4/22/21 (4:15 PM), 4/27/21 (4:15 AM and 11:00 AM), and 4/28/21 (1:10 AM, 6:00 AM, and 9:15 AM). Some progress notes reported that Resident #1 was agitated and anxious after falling, and PRN medication was given as a result. No information was found in the record to document an analysis of the circumstances of the falls and interventions that were initiated to prevent or reduce risk of subsequent falls. Facility staff confirmed that no additional information was present, to document the required information.
Plan of correction
Resident #1 passed away at the hospital.
A review of residents that the UAI indicates the need of mechanical assistance for walking and mobility was completed to verify the ISP is up to date and interventions have been documented. Any issues identified were addressed.
Recent fall events were reviewed to verify a root cause analysis was conducted and documented in the resident's record. The resident ISPs were reviewed to verify interventions have been updated. Any issues identified were addressed.
The Executive Director provided education to the Wellness Department and the Care Coordinators on the use of the UAI to develop interventions based on resident needs. The ED also reviewed conducting a root cause analysis when a fall event occurs and updating an ISP based on resident needs.
Upon move-in, change of condition, semi-annually and annually the resident is evaluated and UAI completed along with an ISP, which includes interventions based on the residents needs. Upon a fall event, the event is evaluated to determine the root causes and the resident record is updated with a revised ISP intervention.
The ED or designee verified the ISP is updated in the resident record.
The POC is evaluated by the ED and coordinators at the monthly Quality Assurance and Performance Improvement (QAPI/Quality Management) meeting for 3 months to ensure it is still effective. If it is no longer effective, it will be amended and a new POC will be implemented and monitored to ensure the violation does not occur again.
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.