9
Inspections
On record
6
With violations
Visits that cited something
3
Clean visits
Nothing cited
18
Violations cited
Individual findings
15
Standards cited
Distinct rules
0
Complaint visits
Prompted by a complaint

Sunrise of Arlington was inspected 9 times between March 10, 2021 and August 15, 2025 by the Virginia Department of Social Services. 6 of those visits ended with violations cited and 3 with none. Across that history VDSS cited 18 violations under 15 distinct standards.

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. 6 of these 9 are still on the state's site; the other 3 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
09/21/2027
Administrator
Katherine Westerman
Licensing inspector
Ishmel Paige
Inspector phone
(804) 963-0360
Approved for
Assisted Living · Special Care Unit · Non-Ambulatory

Inspection History

9

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

August 15, 2025Inspection0 violations
Inspection dates
08/15/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 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: 08/15/2025 Time in: 11:22 AM Time out: 12:24 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 07/29/2025 regarding allegations in the area(s) of: Admission, Retention and Discharge of Residents and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 48 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: 1 Observations by licensing inspector: Licensing inspector observed residents dining for lunch and participating in scheduled activities. Additional Comments/Discussion: 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
July 17, 2025Inspection1 violation
Inspection dates
07/17/2025
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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES
Technical assistance
Licensing inspector reviewed the following standards with the facility: 22VAC40-73-310, 22VAC40-73-490, 22VAC40-73-970.
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: 07/17/2025 Time in: 10:41 AM Time out: 4:21 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: 49 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: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector observed residents dining for lunch, exiting the facility for community outings, and participating in scheduled activities. Additional Comments/Discussion: N/A 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-990-B
Based on record review and staff interview, the facility failed to review resident emergencies at least every six months with all staff. Documentation of the review was signed and dated by each staff person.
Evidence
  1. Upon request, the facility did not provide documentation that the plan for resident emergencies was reviewed at least every six months with all staff.
  2. During the onsite inspection on 07/17/2025, staff 5 confirmed that licensing inspector (LI) was not provided documentation that the resident emergency plan was reviewed every six months.
Plan of correction
A. With respect to the specific resident/situation cited: Residents had no adverse outcomes due to failing to document semi-annual review of resident emergency plan. B. With respect to how the facility will identify residents or situations with the potential for the identified concerns: Following inspection, a review of resident emergency plan has been conducted and documented with current staff. C. With respect to what systemic measures have been put into place to address the stated concern: Review of resident emergency plan has been added semi-annually to community’s annual training calendar. For the next 6 months, Executive Director will confirm with Resident Care Coordinator that review is completed as scheduled. D. With respect to how the plan of correction will be monitored: Documentation of the semi-annual reviews will be presented by the Executive Director at quarterly Quality Assurance and Performance Improvement (QAPI) meeting for quarter three and quarter one to ensure that reviews were completed. After 6 month review period, the Executive Director will re-evaluate effectiveness of POC and extend the review period if necessary.
August 5, 2024Inspection8 violations
Inspection dates
08/05/2024
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 PREPAREDNESS
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: 08/05/2024 Time In: 10:48 AM Time Out: 4:57 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: 42 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: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: LI toured the physical plant of the facility. LI observed participants interacting with one another, dining for lunch and dinner, lounging in the common areas, and participating in activities, such as community outings. Additional Comments/Discussion: 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.
Violations
22VAC40-73-660-A-1
Based on licensing inspector (LI) 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 medication and dietary supplements are administered by the facility. Medications shall be stored in a manner consistent with current standards of practice.
Evidence
  1. On 08/05/2024, LI observed a medication pass.
  2. Staff 3 (hire date, 7/24/2020) removed medications for Resident 3 (admit date, 07/26/2024). Staff 3 pushed the lock of the medication cart halfway so it could be opened without the use of keys. Staff 3 walked away to see if Resident 3 was in her room.
  3. During the same medication pass, Staff 3 walked away from the medication cart, leaving it unlocked to go ask a question regarding Resident 3’s medication. LI prompted Staff 3 to lock the medication cart.
Plan of correction
A. With respect to the specific resident/situation cited: The resident had no adverse outcomes due to medication cart being left unlocked . The medication cart was locked and the MCM was notified. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns:locked when not in use. Resident Care Director (RCD) or designee conducted a medication administration refresher training with Medication Care Managers/ Nurses regarding HIPPA and medication diversion. 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 conduct cart audits weekly for 3 months to confirm that medication carts are secured when not in use. Issues identified will be addressed and resolved. ED/RCD/Designee will observe carts through daily walk-throughs of the community to ensure they are locked daily for 2 weeks. The Resident Care Director or designee will continue to conduct a random audit weekly for 3 months to confirm that medications are secured when the cart is not in use . At the end of the audit, results from the audits will be presented by the resident care director and/or wellness designee at Quality Assurance and Performance Improvement (QAPI) meeting. D. With respect to how the plan of correction will be monitored: POC and monitoring results are reviewed and evaluated by the ED and coordinators at the Quality Management (Quality Assurance and Performance Improvement/QAPI) meeting for quarter four and quarter one 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.
22VAC40-73-830-E
Based on facility record review, the facility failed to ensure that the facility provided a written response to the council prior to the next meeting regarding any recommendations made by the council for resolution of problems or concerns.
Evidence
  1. Resident Council meetings were held on 05/12/2024, 06/5/2024, and 07/2/2024. Residents expressed the need for resident handbook, issues with housekeeping, issues with dining service and food, and resident care issues.
  2. Administration did not provide a written response to the residents prior to 06/25/2024 and 07/2/2024 meetings.
Plan of correction
A. With respect to the specific resident/situation cited: The residents had no known adverse outcomes due to lack of written response to resident council concerns. Executive Director immediately documented written responses and attached it to the resident council forms . B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Executive Director will conduct a review of all resident council notes to ensure a response was received. C. With respect to what systemic measures have been put into place to address the stated concern: The Executive Director or designee will continue to attend all monthly resident council meetings and document concerns brought up in resident council and Executive Director or designee will respond in writing to any concerns and report that back out at future resident council meetings. Executive Director or designee will conduct monthly audits for 8 months to ensure a written response has been documented for resident council each month. The results of the audits will be presented by the Executive Director and/or designee at Quality Assurance and Performance Improvement (QAPI) meeting for 1 year. The Executive Director will re-evaluate and initiate necessary action or extend the review period if necessary. D. With respect to how the plan of correction will be monitored: POC and monitoring results are reviewed and evaluated by the ED and coordinators at the Quality Management (Quality Assurance and Performance Improvement/QAPI) meeting for quarter four and quarter one 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.
22VAC40-73-680-G
Based on resident record review, the facility failed to ensure that over-the-counter medication shall remain in the original container, labeled with the resident’s name, or in a pharmacy-issued container, until administered.
Evidence
  1. Resident 7 (admit date, 09/24/2019) had an order for Ascorbic Acid Tablet 500 MG, which is labeled Caltrate Soft Chews 600+D3 Bone Strength, an over-the-counter medication, was not labeled with Resident 7’s name. The medication only had the resident’s room number written on the packaging.
  2. Video evidence taken.
Plan of correction
A. With respect to the specific resident/situation cited: Resident 7 had no adverse outcome due to over-the-counter medication only having been labeled with the room number and not the resident’s name. Resident Care Director promptly labeled OTC medications with each resident’s name and discussed with families the benefits of switching to Omnicare, where the pharmacy provides labeled, blister-packed OTC medications for safer handling during administration. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Resident Care Director (RCD) conducted eMAR to medication cart audit to confirm Over-the counter medications were properly labeled per physician’s orders. An in-service training with the Medication Care Manager (MCM) on procedure to follow when an over-the-counter medication is missing a label, to report to the Resident Care Director for proper action. C. With respect to what systemic measures have been put into place to address the stated concern: Resident Care Director (RCD) or designee will continue to conduct weekly audits of the med cart monthly for 3 months to verify that over-the-counter medications are properly labeled with the resident’s name per physician orders. Findings from audits will be resolved and taken to QAPI. D. With respect to how the plan of correction will be monitored: POC and monitoring results are reviewed and evaluated by the ED and coordinators at the Quality Management (Quality Assurance and Performance Improvement/QAPI) meeting for quarter four and quarter one 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.
22VAC40-73-970-E
Based on facility record review, the facility failed to ensure that a record of the required fire and emergency evacuation drills shall be kept in the facility for two years.
Evidence
  1. Upon request, the facility did not provide evidence of the completion of emergency evacuation drills for July – December 2023.
  2. January – August 2024 fire drill logs did not contain documentation of the number of residents participating and special conditions.
  3. January, March, April, and August of 2024 fire drill logs did not contain documentation of weather conditions.
  4. January 2024’s fire drill logs did not contain documentation of the identity of the person conducting the drill.
  5. February 2024’s fire drill logs did not contain documentation of the date and time of the drill.
  6. February and March of 2024 fire drill logs did not contain documentation of the time it took to complete the drill.
Plan of correction
A. With respect to the specific resident/situation cited: The residents had no adverse outcomes due to fire and emergency evacuation drills not being accurately and appropriately documented to include weather conditions, person conducting the drill, and the number of residents participating. Executive Director immediately educated the Maintenance Coordinator on the importance keeping records of monthly emergency evacuation drills organized and easy to obtain in the emergency drills binder, documenting the weather conditions on the report each time a drill is ran, and documenting the number of residents participating. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Executive Director conducted an emergency evacuation drill refresher training with Maintenance Coordinator. C. With respect to what systemic measures have been put into place to address the stated concern: The Executive Director or designee will continue to conduct emergency evacuation drills monthly. Monthly audits to confirm all drills are documented and filed away and include the weather conditions and number of residents who participated will be done every month for 8 months. The Executive Director or designee will continue to conduct documentation audits monthly for 8 months to ensure that monthly drills are documented accurately and filled away appropriately. The results of the audits will be presented by the Maintenance Coordinator, ED, or designee at Quality Assurance and Performance Improvement (QAPI) meeting for 8 months. The Executive Director will re-evaluate and initiate necessary action or extend the review period if necessary. D. With respect to how the plan of correction will be monitored: POC and monitoring results are reviewed and evaluated by the ED and coordinators at the Quality Management (Quality Assurance and Performance Improvement/QAPI) meeting for quarter four and quarter
22VAC40-73-980-H
Based on licensing inspector (LI) observation, the facility failed to ensure the availability of 96-hour supply of emergency food and drinking water. At least 48 hours of supply must be on site at any given time, of which the facility’s rotating stock may be used.
Evidence
  1. The emergency water expired March 2024.
  2. On 08/5/2024, LI interviewed Staff 4 who stated, we ran out of emergency water; it expired. I pulled it and we will get more tomorrow, if I get the order in by 3 pm. I checked the emergency food and water once a month. The food should last us a month.
  3. On 08/5/2024, during the findings review, Staff 4 showed LI where the order for emergency water was submitted.
Plan of correction
A. With respect to the specific resident/situation cited: The community had no adverse outcome due to not have a 96 hour supply of non-expired water. Executive Director immediately educated the Dining Service Coordinator on the importance of having a 96-hour supply of water available at the community at all times. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Dining Service Coordinator ordered new supply of water on 8/5/2024 and water was received on 8/12/24 and water expires on 1/21/2026. C. With respect to what systemic measures have been put into place to address the stated concern: The Executive Director, Dining Service Coordinator, or designee will conduct audits quarterly to ensure a 96-hour supply of emergency food and water is always available in the community. The results of the audits will be presented by the Executive Director and/or designee at Quality Assurance and Performance Improvement (QAPI) meeting for 1 year. The Executive Director will re-evaluate and initiate necessary action or extend the review period if necessary. D. With respect to how the plan of correction will be monitored: POC and monitoring results are reviewed and evaluated by the ED and coordinators at the Quality Management (Quality Assurance and Performance Improvement/QAPI) meeting for quarter four and quarter one 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.
22VAC40-73-610-B
Based on licensing inspector (LI) observation, the facility failed to ensure that menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents.
Evidence
  1. On 08/5/2024, LI toured the facility and did not observe a posted weekly menu.
  2. On 08/5/2024, LI interviewed Staff 4 who stated being unaware that the daily menu was not correct.
Plan of correction
A. With respect to the specific resident/situation cited: The residents had no known adverse reactions due to the menu not matching what was being served or being posted out for a week. Executive Director immediately educated the Dining Service Coordinator on the importance of posting accurate daily menus as well as weekly menus. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Dining Service Coordinator posted the weekly menu in the elevator . C. With respect to what systemic measures have been put into place to address the stated concern: The Executive Director, Dining Service Coordinator, and/or designee will conduct daily audits to ensure the menu matches the meal being served for 1 month. The Executive Director, Dining Service Coordinator, and/or designee will conduct monthly audits to ensure the menu matches the meal being served for 8 months. The results of the audits will be presented by the Dining Service Coordinator and/or designee at Quality Assurance and Performance Improvement (QAPI) meeting for 8 months. The Executive Director will re-evaluate and initiate necessary action or extend the review period if necessary. D. With respect to how the plan of correction will be monitored: POC and monitoring results are reviewed and evaluated by the ED and coordinators at the Quality Management (Quality Assurance and Performance Improvement/QAPI) meeting for quarter four and quarter one 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.
22VAC40-73-950-E
Based on facility record review, the facility failed to ensure that the facility developed and implemented 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 should be documented by signing and dating.
Evidence
  1. The emergency preparedness plan was reviewed with 10 staff members on 07/29/2024. The staff list reflects 46 employees.
  2. On 08/5/2024, LI interviewed Staff 6 who stated I just started working on it, so I haven’t reviewed it with all staff. I only got to those 10. This is the only review I have since the last licensing inspection.
Plan of correction
A. With respect to the specific resident/situation cited: The residents had no adverse outcomes due to the Emergency Preparedness Plan not being reviewed by 46 staff members. Executive Director immediately held a review of the Emergency Preparedness Plan with staff present in the community. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Executive Director and/or designee will conduct quarterly Emergency Preparedness Plan reviews with the staff as well as ensure new hires review the Emergency Preparedness Plan with the Executive Director or designee. The Executive Director and/or designee with conduct quarterly audits to ensure staff have reviewed the Emergency Preparedness Plan. C. With respect to what systemic measures have been put into place to address the stated concern: The QAPI meetings will include tracking and trending of quarterly Emergency Preparedness Plan reviews with current staff. During and after each quarter, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. D. With respect to how the plan of correction will be monitored: POC and monitoring results are reviewed and evaluated by the ED and coordinators at the Quality Management (Quality Assurance and Performance Improvement/QAPI) meeting for quarter four and quarter one 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.
22VAC40-73-240-F
Based on facility record review, the facility failed to ensure that prior to beginning volunteer service, all volunteers shall attend an orientation including information on their duties and responsibilities, resident rights, confidentiality, emergency procedures, infection control, the name of their supervisor, and reporting requirements. Volunteers shall sign and date a statement that they have received and understand this information.
Evidence
  1. Staff 14 and Staff 15 did not sign and date a statement that they received orientation training.
  2. On 08/5/2024, Staff 6 provided LI with a criminal background for Staff 14. Staff 6 stated that was all that they had.
  3. On 08/5/2024, LI interviewed Staff 5 who stated they were in the process of recruiting more volunteers. Staff 15 is special needs, so they have not completed a criminal background or training since we sit with Staff 15 when they visit with the residents. Staff 5 stated Staff 14 went out of the country and when they return, they will do a training checklist. Staff 14 worked twice before going out of the country.
Plan of correction
A. With respect to the specific resident/situation cited: The community had no adverse outcomes due to 2 volunteers not having documented orientation and 1 volunteer not having a completed background check. Executive Director immediately educated the Activities and Volunteer Coordinator on the importance obtaining criminal background checks on volunteers and conducting and documenting orientation training with volunteers. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Activities Coordinator and Business Office Coordinator immediately began contacting volunteers to schedule orientation and obtain needed documents for criminal background checks . Criminal background check for staff #15 was received on 8/9/24. Activities Coordinator has not been able to reach staff #14 since she went out of the country on travel to conduct orientation. C. With respect to what systemic measures have been put into place to address the stated concern: The Executive Director, Activities and Volunteer Coordinator, or designee will continue to conduct audits monthly for 8 months to ensure all volunteers have been oriented and that the criminal background checks have been received. The results of the audits will be presented by the Executive Director and/or designee at Quality Assurance and Performance Improvement (QAPI) meeting for 8 months. The Executive Director will re-evaluate and initiate necessary action or extend the review period if necessary. D. With respect to how the plan of correction will be monitored: POC and monitoring results are reviewed and evaluated by the ED and coordinators at the Quality Management (Quality Assurance and Performance Improvement/QAPI) meeting for quarter four and quarter one 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.
September 6, 2023Inspection3 violations
Inspection dates
09/06/2023
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 ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 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: 9/6/23 (8:15 AM - 5:30 PM) Number of residents present at the facility at the beginning of the inspection: 36 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: 6 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.
Violations
22VAC40-73-880-B
Based on observation and interview, the facility failed to ensure that space heaters are only used to supplement or provide heat, in the event of a power failure or similar emergency.
Evidence
  1. A space heater was observed in the room of Resident #8. Facility staff reported that there had been no recent power outages or similar emergencies.
Plan of correction
The facility shall ensure that space heaters are only used to supplement or provide heat, in the event of a power failure or similar emergency by removing the space heater observed in resident #8's room. The Executive Director will review the State code with Community leaders and team. The Resident Care Coordinator will coordinate room sweeps weekly with care staff to verify that no space heaters are present in resident rooms. The Executive Director, Resident Care Coordinator, and 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. The Executive Director and QAPI team are responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving any violation that may occur.
22VAC40-73-680-D
Based on documentation, 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 registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident #7's MARs (medication administration records) were reviewed during the inspection. Resident #7's MAR stated that the resident was administered Midodrine on 8/6/23 (BP: 149/86) and 8/24/23 (BP: 135/88). Resident #7's MAR calls for her Midodrine to be held, if her SBP is greater than 120.
Plan of correction
Resident Care Director (RCD) provided 1:1 in-service/training to Medication Care Manager (MCM) on "giving medication with parameters" on the Electronic Medication Administration Record (eMAR) for Resident #7 on 9/13/23. Resident Care Director (RCD) will conduct audits of the eMARs to verify that medications are administered within parameters per physician orders. Training will be completed by Resident Care Director with the Med Care Managers regarding the process and procedures for medication management with parameters. The RCD will present the results of the audits to the Quality Assurance and Performance Improvement (QAPI) Committee for three months. During and at the end of the three-month period, the QAPI Committee will evaluate the results of the audit and determine if additional focus or action is needed. Weekly, monthly, and quarterly audits to confirm medications are administered within parameters per physician order. Review results in monthly Quality Assurance and Performance Improvement (QAPI) meetings. The Executive Director or Designee is responsible for the implementation and ongoing compliance with the components of the Plan of Correction as outlined.
22VAC40-73-1110-B
Based on record review, the facility failed to ensure that a review of continued appropriateness, is completed six months after a resident is placed in the safe, secure environment.
Evidence
  1. The record for Resident #3, admitted 10/10/22, was reviewed during the inspection. Resident #3's record contained a review of continued appropriateness, dated 8/30/23. Resident #3's record did not contain a review of continued appropriateness, six months after the resident was placed in the safe, secure environment.
Plan of correction
The Executive Director completed a review of continued appropriateness after a resident is placed in the safe, secure environment on 8/20/23. This review of appropriateness of continued residence in special care unit was placed in Resident #3's file. An audit of current memory care resident's review of continued appropriateness of continued residence in special care unit was performed on 8/30/23 to verify each resident has a review of appropriateness of continued resident in special care unit was placed in resident files. Resident Care Director and Neighborhood Coordinators have been trained to verify that current memory care residents are reviewed for appropriateness of continued residence of special care unit and that current review of continued appropriateness form are completed at least every six months. Quarterly audits for three quarters, will be conducted by the Resident Care Director and/or Executive Director to verify each resident in memory care has a current review of continued appropriateness form. During the QAPI meeting and up to three months following the implementation of the POC, the Executive Director will review the POC and the results of the audit with the Department Coordinators. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
October 31, 2022Inspection2 violations
Inspection dates
10/31/2022
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: 10/31/22 (8:50 AM – 12:55 PM) 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 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-D
Based on observation and documentation, 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 registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. The October medication administration record (MAR) for Resident #1 was reviewed during the inspection. Resident #1 has an order for Amlodipine Besylate, dated 4/16/20, that calls for him to receive a 10mg tablet once per day. Resident #1 was not administered Amlodipine Besylate on 10/14/22. The MAR note stated that the resident’s vitals were outside the parameters. No parameters were included in Resident #1’s order for Amlodipine Besylate. The morning medication administration, for Resident #2, was observed during the inspection. Resident #2. Resident #2 has an order for Famotidine, dated 3/27/22, that calls for the resident to receive the medication every 12 hours. Resident #2 did not receive Famotidine during the medication administration, as it was not present in the medication cart. Resident #2’s MAR showed that there were 22 does of Famotidine that were not given, as the medication was “pending delivery.”
Plan of correction
Resident Care Director received new order from physician and updated the Medication Administration Record (MAR) for Resident #1 on 10/31/22. Resident Care Director contacted pharmacy to notify pharmacy that Resident #2 was out of current scheduled medication as ordered on 10/31/22. Resident #2 did not exhibit adverse reaction from missed doses. Resident Care Director (RCD) /Wellness nurse (WN) /Medication Care Manager (MCM) will utilize the medication management plan and program, as outlined with the processes and procedure of medication administration. Resident Care Director (RCD) /Wellness nurse (WN) /Medication Care Manager (MCM) will follow up with pharmacy concerning any pending medications to confirm resident medications are available for administration. Resident Care Director (RCD)/ Wellness nurse (WN) conducted audits of the EMARs and Med Carts to confirm medications available and administered as scheduled per physician orders. Training will be completed by Resident Care Director with the Wellness nurse and Med Care Managers regarding the process and procedures for medication management. Training will be completed by Resident Care Director with the Wellness nurse and Med Care Managers regarding procedures for pending medications. Resident Care Director (RCD)/Wellness nurse (WN) will conduct random audits of the EMARs and Med Carts weekly x 4 weeks (11/29/22), monthly x 3 months (1/24/23) to confirm medications are available and administered as scheduled per physician orders. The RCD will present the results of the audits to the Quality Assurance and Performance Improvement (QAPI) Committee for three months. During and at the end of the three-month period, the QAPI Committee will evaluate the results of the audit and determine if additional focus or action is needed. Weekly, monthly, and quarterly Med cart audits will continue to confirm medications are available for administration. Review results in monthly Quality Assurance and Performance Improvement meetings. The Executive Director or Designee is responsible for the implementation and ongoing compliance with the components of the Plan of Correction as outlined.
22VAC40-73-530-B
Based on observation, 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, 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.
Evidence
  1. The main entrance door was unable to be opened from inside the building at 8:55 AM, during the inspection. The door was pushed for 15 seconds, an alarm sounded, and then the door was able to be opened. A keypad is located next to the door, and a code can be entered to release the door’s security. The Arlington County Fire Prevention Office was contacted about the facility’s permit to secure the entrance doors. The Fire Prevention 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 the residents to common areas and to their personal spaces. 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 Administrator/Executive Director will review the State code with Community leaders and team and ensure that resident in Assisted living has access to exit the community’s front door with ease 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. 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. The Executive Director and QAPI team are responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving any violation that may occur.
August 17, 2022Inspection3 violations
Inspection dates
08/17/2022
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 IMPAIRMENTS32.1 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: 8/17/22 (8:30 AM – 6:30 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: 41 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 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. Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Violations
22VAC40-73-260-A
Based on record review, the facility failed to ensure that direct care staff members maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Each direct care staff member who does not have current certification in first aid, shall receive certification in first aid within 60 days of employment.
Evidence
  1. The record for Staff #2, hired 6/17/22, was reviewed during the inspection. No documentation was provided, during the inspection, to indicate that Staff #2 received first aid certification within 60 days of being hired.
Plan of correction
Facility (BOC office) will ensure a periodic (monthly/quarterly) review of team member’s files to ensure that all staff files have the needed and required documentations/records. At the time of the inspection, Staff #2 had CPR but no First Aid: She was scheduled for CPR and First Aid on 08/24/22. As of 8/24/22, Now Staff #2 is certified in both CPR and Frist Aid. Moving forward facility will be on top of with 60 days requirement by routinely and frequently auditing of new team Member files. The Business Office Coordinator will review and audit team member and new hire files to ensure that all required standards pertaining to CPR/First Aid are met in accordance with State regulations. The Business office Coordinator will review Team members file Bi-monthly to confirm they reflect the standards required. On a quarterly review, the leadership team will evaluate the results of the reviews and determine if additional focus or action is warranted during Monthly Quality Assurance and Performance Improvement (QAPI) meetings. The Executive Director and QAPI Team is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur. During and at the end of each quarterly review, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results and determine if additional focus or action is warranted.
22VAC40-73-680-D
Based on observation and 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 registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. The August medication administration record (MAR) for Resident #1 was reviewed during the inspection. Resident #1 has an order for insulin, dated 4/6/22, that called for her to receive 5 units of insulin before meals. During the morning medication administration on 8/3/22, Resident #1 was not administered insulin. The MAR note stated that she was to receive no coverage. No parameters, for insulin administration, were included on the order. No instructions were provided, during the inspection, to indicate why the insulin was during the morning administration on 8/3/22. The August medication administration record (MAR) for Resident #9 was reviewed during the inspection. Resident #9’s MAR indicated that her Levothyroxine, ordered 7/13/22, was not available for administration on 8/10/22 and 8/11/22. The MAR note stated that the medication was “pending delivery.”
Plan of correction
There were no negative outcomes as a result of Resident # 1 not receiving medication timely and Resident #9 insulins parameter. The Resident Care Director has called the MD for verification and parameter order to hold insulin in the event of low blood sugar for Resident #1. Resident #9 had an order from an outside MD for Levothyroxine, Resident Care Director has validated and reviewed each order for accuracy and inconsistency. The Resident Care Director and Med Techs has reviewed the standards regarding insulin injections and audit of written orders to identify incorrect orders/prescription from MD; this process will be an ongoing and routine. Team member was counseled, and Med Techs reviewed policy and procedures on orders and to refer to MD orders on eMAR. The Resident Care Director, or Wellness Nurse is completing Med audits each month to confirm they reflect the needs/prescriptions for care of each resident. The leadership team Executive Director, QAPI Team) will evaluate the results of the Med reviews and determine if additional focus or action is warranted during Monthly Quality Assurance and Performance Improvement (QAPI) meetings. The Resident Care Director or designee will present the results of the medication cart audits to the Quality Assurance and Performance Improvement (QAPI) Committee for 3 months. During and at the end of the 3 months the Quality Assurance and Improvement Committee will evaluate the results of the EMAR to medication cart 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.
22VAC40-90-40-G
Based on record review, the facility failed to ensure that a criminal history record report is obtained, on or prior to the 30th day of employment, for each employee.
Evidence
  1. The criminal history record reports of new staff members were reviewed during the inspection. One out of 13 new staff records (Staff #5) did not contain a criminal history record report. Staff #5 was hired on 8/27/21.
Plan of correction
Facility will ensure a periodic (monthly/quarterly) review of team member’s files to ensure that all staff files have the needed and required documentations/records. Moving forward BOC will audit team member files consistently. At the time of the inspection, a state background check was conducted for Staff #5 (08/17/22), was presented to the inspector and was accepted, then placed on Staff #5’s file. The Business Office Coordinator is reviewing and auditing team member and new hire files to ensure that all required documentation and standards pertaining to criminal background are met in accordance with State regulations. The Business office Coordinator (BOC) will review Team members file Bi-monthly to confirm they reflect the standards required. On a quarterly review, the leadership team will evaluate the results of the reviews and determine if additional focus or action is warranted during Monthly Quality Assurance and Performance Improvement (QAPI) meetings. The Executive Director and QAPI Team is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving any violations that may occur. During and at the end of each quarterly review, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate that, all new TM files will be viewed/signed by The Executive Director before they are filed in the BOCs office.
August 4, 2021Inspection0 violations
Inspection dates
Aug. 4, 2021
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 ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 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 LICENSE
Comments
A renewal inspection was initiated on 8/4/21 and concluded on 8/12/21. The business office coordinator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 41. 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, activities calendar, fire inspection, and health inspection submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 8/6/21. An exit interview was conducted with the administrator on the date of the inspection 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. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
May 13, 2021Inspection1 violation
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 ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 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 LICENSE
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 5/13/21 and concluded on 5/18/21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the census was 37. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, medication administration records, local fire and health inspections, and other documentation submitted by the facility to ensure documentation was complete. 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. 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 standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail 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 registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident #3's April MAR (medication administration record) was reviewed during the inspection. Resident #3's record contained an order for Baclofen, dated 12/21/20, that called for the resident to receive 5mg by mouth two times per day. The MAR documented that Resident #3' s Baclofen was not administered on 4/17/21 (7 PM administration). The MAR documented that the medication was not administered, as the medication was "pending delivery." Resident #3's record contained a PRN order for Lasix, dated 2/15/21, that called for the resident to receive one 20mg tablet every 24 hours as needed. The MAR states that the medication was given when less than 24 hours elapsed between the administrations on 4/5/21 (11:01 AM) and 4/6/21 (9:58 AM).
Plan of correction
Resident #3 did not have any negative outcomes and both medications, Baclofen and Lasix, are available for administration. The Resident Care Director conducted eMAR to medication cart audit to confirm medications were available and timely administered per physician's order. Refresher training with medication care managers and nurse was conducted by the Resident Care Coordinator regarding procedures to follow in order to timely administer medications in accordance with the physician's order. When MCM is unable to locate a medication, the MCM is to check the cart to verify it has not been stored incorrectly, to report to the RCD and notify the physician. If medication aide is unable to locate, the medication will be re-ordered. The Resident Care Director or designee will continue to conduct eMAR to medication cart audits weekly for 3 months to confirm that medications are available and timely administered per physician's order. 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 in order to correct any deficient practices. The Executive Director 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.
March 10, 2021Inspection0 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS63.2 General Provisions63.2 Licensure and Registration Procedures63.2 Facilities and Programs
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. An initial inspection was initiated on 3/10/21 and concluded on 3/12/21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 36. The inspector emailed the administrator a list of required items to complete the inspection. Facility reports, documents, and inspections were reviewed. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.