VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Crossroads at Bon Air
9100 Bon Air Crossings Drive
Richmond, VA 23235
(804) 560-1440

Current Inspector: Tamara Watkins (804) 662-7422

Inspection Date: Nov. 18, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

An unannounced complaint inspection was completed on this date from 12:00 - 2:03 PM. The areas of complaint were regrading slow staff response time to the call bell and frequent modifications to the daily menu. The complaints are considered valid and violations were cited.Areas of non-compliance are identified in the Violation Notice. The facility has 10 calendar days from receipt of the inspection reports to complete a plan of correction, sign the inspection report and return them to the licensing office. A copy of the inspection reports shall be retained and posted at the facility. Results of the inspection are subject to public disclosure and will be posted on the VDSS website within 15 calendar days, regardless of whether the plan or correction is completed. The plan of correction shall include the following: (1) Step(s) the facility will take to correct the violations cited; (2) Measures that will be put in place to prevent recurrence of each violation; (3) Person(s) responsible for implementation and monitoring of preventive measures; and (4) Date by which each violation will be corrected.

Violations:

Standard #:	22VAC40-73-460-B
Complaint related:	Yes
Description:	Based on interviews with residents and a random review of the call bell log, the facility failed to provide prompt response by staff to the residents needs so that care provision and service delivery were resident centered to the maximum extent. Evidence: According to the documentation indicating when the call bells are activated and answered provided by the facility there were nine instances in September, 2019 where it took from 8-21 minutes for staff to respond to a call bell on the 7-3 shift. There were four instances on November 16, 2019 on the 3-11 shift where it took from 12-23 minutes for staff to respond to a call bell. During November 17, 2019 on the 3-11 shift there were five instances where it took from 9-22 minutes for staff to respond. Of the five instances there were two ocassions when the call bell timed out and was not answered prior to the time the system was reset. .
Plan of Correction:	All current staff will be in serviced prior to their next shift no later than 1/20/2019 on the Meridan/CABA standard regarding call bell response times, demonstrations to reset call bell and resident individual pendant responding to during their orientation as scheduled. Training will conducted by Director of Wellnes, Maintenance or designee. All new hires will be in serviced on the Meridian/Crossings at Bon Air standards regarding all bell response time demonstrations to reset call bell and resident individual pendant responding to during their orientation as scheduled. Training will conducted by Director of Wellnes, Maintenance or designee. The ED/ designee will audit call bell response times daily for the next 30 days and no less than weekly thereafter for two months to assist with compliance. Any response times outside of Meridan/Crossings at Bon Air standards will be addressed immediately. Findings will be reported to the Quality Assurance Committee for follow-up as needed.
Standard #:	22VAC40-73-610-B
Complaint related:	Yes
Description:	Based on a review of the menu posted on the day of inspection menu substitutions were not recorded on the posted menu. Evidence: The lunch menu on the day of inspection listed the dessert as Baked Apple Pudding which was substituted with pound cake and the change was not recorded on the menu.
Plan of Correction:	Substitutions will be posted on menus in designated areas (kitchen, DR and concierge desk). Staff will be in serviced regarding proper posting by ED, DSD, or designee completed by January 20, 2020. The DSD/designee will audit menus weekly for four weeks, and then monthly for two months to assist with compliance. Findings will be reported to the Quality Assurance Committee for follow up as needed.