VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise at Bon Air
2105 Cranbeck Road
Richmond, VA 23235
(804) 560-7707

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: June 17, 2022

Complaint Related: No

Areas Reviewed:

? 22VAC40-73 GENERAL PROVISIONS ? 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES ? 22VAC40-73 PERSONNEL ? 22VAC40-73 STAFFING AND SUPERVISION ? 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS ? 22VAC40-73 RESIDENT CARE AND RELATED SERVICES ? 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS ? 22VAC40-73 BUILDINGS AND GROUND ? 22VAC40-73 EMERGENCY PREPAREDNESS ? 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ? ARTICLE 1 ? SUBJECTIVITY ? 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS ? 63.2 GENERAL PROVISIONS ? 63.2 PROTECTION OF ADULTS AND REPORTING ? 63.2 LICENSURE AND REGISTRATION PROCEDURES ? 63.2 FACILITIES AND PROGRAMS ? 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES ? 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION ? 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT ? 22VAC40-80 THE LICENSE ? 22VAC40-80 THE LICENSING PROCESS ? 22VAC40-80 COMPLAINT INVESTIGATION ? 22VAC40-80 SANCTIONS

Technical Assistance:

Items in Special Care Unit - labeling

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: 6/17/2022, 9:15 a.m. ? 2:52 p.m. 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 Number of resident records reviewed: 10 Number of staff records reviewed: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility, meal observation, medication pass, review of records. 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 Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1100-C
Description:	Based on record review, the facility failed to document that the order of priority specified in subsection A of this section was followed (Prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the written approval of one of the following persons, in the following order of priority), and the documentation shall be retained in the resident's file. Evidence: 1. Resident #10 admitted 3-02-2016 to the facility and relocated to the facility Special Care Unit (SCU) in July 2021. On the ?Approval for Placement in Special Care Unit? form, it was blank for ?Explanation of why written approval was not obtained from each individual higher on the list of priority.? 2. Staff #1 confirmed during interview.
Plan of Correction:	A. With respect to the specific resident/situation cited: Resident #10's Approval for Special Placement Form was reviewed by the Executive Director and the form was amended to include a response and explanation of why written approval was not obtained from each individual higher on the list of priority of the form. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Executive Director conducted an audit of Reminiscence resident's Approval for Placement in Special Care Unit forms to confirm that the section, "To be completed by assisted living facility. Explanation of why written approval was not obtained from each individual higher on the list of priority" was completed correctly. Any forms missing this section was updated accordingly and signed and dated with the date of the change. C. With respect to what systemic measures have been put into place to address the stated concern: New Reminiscence resident's Approval for Placement in Special Care Unit forms reviewed by the Resident Care Director or designee, prior to move in to confirm that the section, "To be completed by assisted living facility. Explanation of why written approval was not obtained from each individual higher on the list of priority" was completed correctly. D. With respect to how the plan of correction will be monitored: During the QAPI meeting and up to 3 months following the implementation of the 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.
Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility that contained a description of the person?s reaction to any known allergies. Evidence: 1. Resident #9 admitted 6-30-2021. The resident?s ?Physician?s Move in Orders? consistent with the physical examination form documented allergies of Cephalexin, Codeine Phosphate, Diazepam, Penicillin, and Pentazocine-Naloxone; however, the form didn?t request allergy reactions and allergy reactions were not provided.
Plan of Correction:	A. With respect to the specific resident situation cited: The physician for resident #9 was notified by the Wellness Nurse of the "Physician's Move in Orders" (physical examination forms) did not include the question regarding allergy reactions. The physicians provided the responses, and the forms were updated. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: An audit was conducted of resident's physical examination forms to verify they are complete and include the question regarding allergy reactions and response if applicable. Any forms missing allergy reaction question and/or responses will be communicated with the respective physician for updating. C. With respect to what systemic measures have been put into place to address the stated concern: The process for reviewing physical examination forms upon receipt for complete responses to required fields and questions was reviewed with the nursing staff. The Director of Sales, Resident Care Director and Wellness Nurses have been in serviced on reviewing physical examination forms upon receipt for complete responses to all required fields and questions. The Resident Care Coordinator or designee reviews new admission physical examination forms to verify the form is complete with responses to required fields and questions D. With respect to how the plan of correction will be monitored: During the QAPI meeting and up to 3 months following the implementation of the 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.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the comprehensive individualized service plan (ISP) included a description of identified needs and date identified based upon the Uniform Assessment Instrument (UAI) and other sources. Evidence: 1. Resident #1 admitted 4-14-2022. Resident #1?s UAI dated 4-14-2022 documented resident requires no assistance with money management; however, the resident?s comprehensive ISP dated 4-22-2022 documented on 4-14-2022 under Finances, ?Family, resident or resident?s representation manages all financial matters independently.? 2. Resident #2 admitted 3-01-2022. Resident #2?s UAI dated 3-01-2022 document resident requires no assistance with laundry; however, the resident?s comprehensive ISP dated 3-04-2022 documented on 3-01-2022 under Laundry, ?My laundry for linen and clothing is performed by my family?. 3. Resident #4 admitted 8-31-2014. Resident #4?s UAI dated 1-06-2022 documented under Behavior Pattern (where options include ?Wandering ? Less than Weekly or Weekly or More?), as ?Appropriate?; however, the resident?s comprehensive ISP dated 1-16-2022 documented, ?I am an elopement risk/wanders?, and ?I wander less than weekly?. 4. Resident #6 admitted 2-11-2019. Resident #6?s UAI dated 1-27-2022 documented ?Mechanical help? with stairclimbing; however, the comprehensive ISP dated 4-04-2022 documented under Stairclimbing, ?I do not climb the stairs due to no stairs in the Sunrise community.? Additionally, the UAI documented, no assistance with money management; however, the ISP under Finances, ?Family, resident or resident?s representative manages all financial matters independently.? 5. Resident #8 admitted 3-03-2018. Resident #8?s UAI dated 5-24-2022 documented no assistance for bathing; however, the comprehensive ISP dated 5-28-2022 documented under Bathing Assistance, ?My bathing care needs will be provided by Sunrise Care Team, my bathing care needs will be provided in my room, I need a shower/tub chair to assist with bathing, I need grab bars to assist with bathing, Observe for and report any changes in bathing assistance, Observe for and report any changes in my bathing ability, I am independent with bathing.? Under Bathing Preferences, the ISP documented, ?I prefer to take a shower or sponge bath daily ? HOSPICE COMPLETES MY SHOWERS/BATHS IF HOSPICE IS NOT AVAILABLE PLEASE MAKE SURE ITS COMPLETED?. 6. Resident #7 admitted 6-30-2021. Resident #7?s UAI dated 5-05-2022 documented ?human help, physical assistance? under bathing; however, the comprehensive ISP dated 6-17-2022 documented under Bathing Assistance, ?My bathing care needs will be provided by Sunrise Care Team. My bathing care needs will be provided in My Apartment on Tuesday Mornings. I need a shower/tub chair to assist with bathing. I need grab bars to assist with bathing. Observe for and report any changes in my bathing ability. I need physical assistance of 1 person with bathing. Encourage me to participate with bathing as much as possible.? The UAI documented under Walking, ?mechanical help only?; however, the ISP documented under Walking, ?I need a walker to assist with walking. I am independent with Mechanical Help with walking. I do not walk due to (POST LEFT HIP FX).? 7. Staff #1 confirmed the above mentioned above during interview.
Plan of Correction:	A. With respect to the specific resident/situation cited: The Assisted Living Coordinator and Resident Care Director have reviewed the UAI and ISP for Residents #1,2,4,6,8 and 7 and included a description of identified care needs and date. Resident #1 's UAI and ISP were reviewed to verify needs identified were captured on the ISP. The ISP was updated to reflect that the resident requires family assistance with money management. Resident #2's UAI and ISP were reviewed to verify needs identified were captured on the ISP. The UAI was updated to reflect that the resident requires assistance with laundry, provided by family. Resident #4's UAI and ISP were reviewed to verify needs identified were captured on the ISP. The UAI was updated to reflect that the resident wanders less than weekly. Resident #6's UAI and ISP were reviewed to verify needs identified were captured on the ISP. The ISP was updated to reflect that the resident requires mechanical assistance with stairclimbing and the UAI was updated to reflect assistance with money management. Resident #8's UAI and ISP were reviewed to verify needs identified were captured on the ISP. The UAI was updated to reflect that the resident requires mechanical and human assistance with bathing. The ISP was updated to reflect that the resident requires grab bars and a shower chair for bathing with assistance by Hospice or Sunrise. Resident #7's UAI and ISP were reviewed to verify needs identified were captured on the ISP. The ISP was updated to reflect that the resident requires B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Assisted Living and Reminiscence Coordinators have audited resident UAls and ISPs to confirm resident care needs were captured on the ISP. C. With respect to what systemic measures have been put into place to address the stated concern: Upon completion of the UAI and ISP the designated Coordinator will review the contents of both documents to verify they are complete and consistent with the information documented. D. With respect to how the plan of correction will be monitored: During the QAPI meeting and up to 3 months following the implementation of the 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.
Standard #:	22VAC40-73-450-D
Description:	Based on record review, the facility failed to ensure 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: 1. Resident #10 admitted 3-02-2016. The resident?s ?Hospice IDG Comprehensive Assessment and Plan of Care Update Report? documented the start of care for services for the resident as 2-02-2022, and the latest recertification for hospice care services was through 7-31-2022. Resident #10?s most current ISP was dated 1-16-2022 and did not document hospice services were in place. 2. Staff #1 acknowledged the aforementioned information
Plan of Correction:	A. With respect to the specific resident/situation cited: The Assisted Living Coordinator has reviewed and updated resident #10's ISP to include Hospice Services. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Assisted Living and Reminiscence Coordinators will audit ISPs of residents receiving Hospice Services to confirm services are included on the individualized service plan. C. With respect to what systemic measures have been put into place to address the stated concern: Upon a resident beginning hospice service, the Resident care Coordinator or designee will update the ISP with information of the Hospice agency and services being provided. Upon completion of updating the ISP the respective Care Coordinator will review the ISP to verify it has been updated with information of the Hospice agency and services being provided. Changes in resident care will be communicated with the care managers. D. With respect to how the plan of correction will be monitored: During the QAPI meeting and up to 3 months following the implementation of the 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.
Standard #:	22VAC40-73-960-B
Description:	Based on observation, the facility failed to ensure the fire and emergency evacuation drawing showed primary and secondary escape routes, areas of refuge, assembly areas, and fire alarm boxes. Evidence: Photographic evidence obtained on 6-17-2022 showed the facility fire and emergency evacuation drawing documented ?exit route?, ?telephone?, ?fire extinguisher? and ?alarm?; however, no primary and secondary routes were identified, nor were the areas of refuge or assembly areas.
Plan of Correction:	With respect to the specific resident/situation cited: The facility fire and emergency evacuation drawing has been updated to include the primary and secondary evacuation route, as well as areas of refuge, assembly areas, and fire alarm boxes. The new document has been posted. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Maintenance Coordinator has inspected Emergency Evacuation drawings to verify drawings include primary and secondary escape routes, areas of refuge, assembly areas, and fire alarm boxes. C. With respect to what systemic measures have been put into place to address the stated concern: Annually the Maintenance Coordinator will review the regulatory requirements for emergency evacuation drawing and verify changes to the drawings are not required. If so, the drawing will be updated to meet regulatory requirements and re-posted. Training will be provided to team members as needed. D. With respect to how the plan of correction will be monitored: During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months, the Executive Director and Department Heads will review the Plan of Correction (POC) to verify implementation. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
Standard #:	22VAC40-73-980-H
Description:	Based on record review and interview with staff, the facility failed to ensure at least 48 hours of the emergency food supply was on site at any given time. Evidence: 1. Staff #2 escorted the licensing inspector offsite on 6-17-2022 to the storage unit where the emergency food is kept approximately .5 miles down the road. 2. The facility emergency food supply was not kept onsite at any given time as confirmed by Staff #1 and Staff #2.
Plan of Correction:	A. With respect to the specific resident/situation cited: The Dining Service Coordinator has relocated the 48 hours of emergency food supply from the offsite storage to onsite secure storage area. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The facility practice of storing emergency food supply offsite is discontinued. C. With respect to what systemic measures have been put into place to address the stated concern: As the emergency food supply is replenished it will be stored onsite at the community. The Dining Service Coordinator will conduct monthly inspections of emergency food supply onsite to confirm at least 48 hours of supply available. D. With respect to how the plan of correction will be monitored: During the QAPI meeting and up to 3 months following the implementation of the 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.