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: Oct. 13, 2022

Complaint Related: Yes

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 XX 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:

Other non-prescription, OTC items kept in resident rooms

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10-13-2022, 8:20 ? 11:00 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 9-06-2022 regarding allegations in the area of Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 80 Number of resident records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on record review and interview with staff, the facility failed to ensure the UAI was completed at least annually. Evidence: 1. Resident #4 admitted 6-2-2021. Resident #4?s current UAI was not in the record. Staff did not produce a UAI when requested onsite or after inspection.
Plan of Correction:	A. With respect to the specific resident/situation cited: Resident #4; Neighborhood Coordinator acquired verification with resident responsible party (RP) for the UAI dated 8-13-2022. This UAI was placed in resident?s record. B. With respect to how the facility will identify situations with the potential for the identified concerns: An audit of current resident UAIs will be performed to verify compliance of responsible party (RP) review and sign-off. An audit of current resident UAI?s was performed to verify each resident has a current UAI and that UAI?s are being completed at least annually C. With respect to what systemic measures have been put into place to address the stated concern: Wellness Nurses and Neighborhood Coordinators have been trained to verify that current UAIs are in resident records and that UAI?s are being completed at least annually. Quarterly audits, for three quarters, will be conducted by the Resident Care Director and/or the Executive Director to verify each resident has a current UAI and UAIs will be completed annually. 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 Coordinators. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on record review and interview with staff, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the resident or his legal representative. These requirements shall also apply to reviews and updates of the plan. Evidence: 1. Resident #1 admitted 8-21-2020. Resident #1?s ISP dated 8-6-2022 was last signed by the facility staff; however, the last signature from Resident #1?s responsible party was 8-5-2021. 2. Staff #1 confirmed the ISP was not signed by the resident or responsible party for updates of the ISP.
Plan of Correction:	A. With respect to the specific resident/situation cited: Resident #1?s ISP was reviewed by the staff, resident, and responsible party. All signatures obtained and documentation filed. B. With respect to how the facility will identify situations with the potential for the identified concerns: An audit of current resident ISPs will be performed to verify that staff, resident and responsible party have reviewed the specifics of the ISP and signatures have been obtained. C. With respect to what systemic measures have been put into place to address the stated concern: Wellness Nurse and Neighborhood coordinators have received education on best practices to ensure all ISP?s are review by staff, residents, and RPs to ensure ISP?s are properly documented and executed. A quarterly audit, for three quarters, will be conducted for by the Resident Care Director and/or the Executive Director to ensure resident and/or responsible party signed/executed acknowledgement and agreement on resident ISP. 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 Coordinators. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on record review and interview with staff, the facility failed to ensure the individualized service plans (ISP) was reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. Resident #5 admitted 2-17-2020. Resident #5?s most recent update of the ISP was dated 8-24-2021. 2.Staff #1 confirmed during the inspection that the resident?s ISP was outdated during interview.
Plan of Correction:	A. With respect to the specific resident/situation cited: Resident #5?s ISP was updated on 7/22/22. The current ISP was reviewed by staff, resident and responsible party to verify content. All signatures obtained and documentation filed. B. With respect to how the facility will identify situations with the potential for the identified concerns: An audit of current resident ISPs will be performed to verify compliance of accuracy of resident conditions, all signatures obtained, and documentation filed. C. With respect to what systemic measures have been put into place to address the stated concern: Wellness Nurses and Neighborhood coordinators have received education on ensuring that all parties have reviewed compliance components for ISP?s. A quarterly audit, for three quarters, will be conducted for by the Resident Care Director and/or the Executive Director to ensure resident and/or responsible party signed/executed acknowledgement and agreement on resident ISP. 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 Coordinators. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
Standard #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on record review and interview with staff, the facility failed to implement a written plan for medication management including methods to ensure that each resident's prescription medications and any over- the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: 1. The facility?s policy ?Medication Not Available? dated 03-2021 documents, ?Every effort should be made to proactively order/reorder medications to avoid medications not being available when needed.? 2. The key code for MD on the facility?s Medication Administration record (MAR) documented it stands for ?medication pending delivery?. The following resident?s medications were marked MD on the following dates: a. Resident #1 - Ensure Liquid on 8-3-2022 and 8-4-2022 twice a day, and Acetaminophen 5 ml 8-2-2022 twice out of three times. b. Resident #2 - Vitamin D Capsule 50 mcg on 7-14-2022 and 7-15-2022, and 8-5-2022, 8-7-2022, 8-8-2022, 8-10-2022, and 8-11-2022. c. Resident #3 - Lubricating Jelly Gel nostrils 8-1-2022 ? 8-3-2022 AM, 8-3-2022 PM, 8-4-2022 AM, 8-6-2022 through 8-8-2022 AM/PM, 8-9-2022 AM, 8-10-2022 AM/PM, 8-11-2022 AM, 8-12-2022 AM, 8-15-2022 AM/PM, 8-16-2022 through 8-22-2022 AM, 8-17-2022 PM and 8-19-2022 through 8-22-2022 PM 8-24-2022 AM/PM, 8-25-2022 AM, 8-26-2022 AM/PM, 8-27-2022 through 8-31-2022 AM, 8-27-2022 PM, 8-29-2022 PM, and 8-31-2022 PM; Colace 2-n-1 8-6-2022 PM, 8-17-2022 AM, 8-18-2022 AM, 8-20-2022 AM. d. Resident #5 - Trazodone 7-1-2022 and 8-17-2022 through 8-23-2022.
Plan of Correction:	A. With respect to the specific resident/situation cited: Resident #1 did not experience any adverse effects. Resident #1?s Ensure Liquid and Acetaminophen 5ml was ordered and obtained immediately. The medication was received and is available for administration. Resident #2 did not experience any adverse effects. Resident #2?s Vitamin D Capsule 50 mcg was ordered and obtained immediately. The medication was received and is available for administration. Resident #3 did not experience any adverse effects. Resident #3?s Lubricating Jelly Gel nostrils was ordered and obtained immediately. The medication was received and is available for administration. Resident #5 did not experience any adverse effects. Resident #5?s Trazodone was ordered and obtained immediately. The medication was received and is available for administration. B. With respect to how the facility will identify situations with the potential for the identified concerns: The Wellness Nurses conduct daily audits of the medications pending delivery and follow up with the Medication Care Managers (MCM) and the Pharmacy to verify medications are delivered timely. C. With respect to what systemic measures have been put into place to address the stated concern: The Resident Care Director (RCD) or Designee will re-educate Medication Care Managers, by utilizing the medication management plan and program, on the processes and procedure to confirm that resident medication is available as prescribed by the physician(s). The MCMs were re-educated to continue to report disparities to the RCD or Wellness Nurses so that any discrepancy can be addressed timely by the pharmacy and physicians. The RCD or Designee will conduct the refresher training on monthly bases for (2) quarters. The RCD or the Wellness Nurse (WN) conduct random audits of the e-MARs and Medication Carts weekly for three months to confirm that medications are available as prescribed by the physician(s). D. With respect to how the plan of correction will be monitored: The RCD or designee 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 warranted. 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.
Standard #:	22VAC40-73-660-B
Complaint related:	Yes
Description:	Based on observation and interview with staff, the facility failed to ensure a resident may be permitted to keep his own medication in an out-of-sight place in his room if the UAI has indicated that the resident is capable of self-administering medication. The medication and any dietary supplements shall be stored so that they are not accessible to other residents. Evidence: 1. During a tour of the facility on 10-13-2022, the following was observed: a. Resident #3?s bathroom contained a barrier cream that is prescribed to the resident. Resident #3?s UAI dated 5-24-2022 documented that the resident?s medications are to be administered by professional nursing staff.
Plan of Correction:	A. With respect to the specific resident/situation cited: Resident #3?s barrier cream was removed from bathroom during the inspection and placed in the secured medication cart. B. With respect to how the facility will identify situations with the potential for the identified concerns: The Assisted Living Neighborhood Coordinators conducted rooms sweeps at the time of the inspection to verify that all prescription medications identified as being administered by professional nursing staff were secured on the medication cart. C. With respect to what systemic measures have been put into place to address the stated concern: All medication aides upon hire will be trained on securing medications from being available to residents. On a quarterly basis all medication aides are trained on the process of securing prescribed medications from being available to residents. The Assisted Living and Reminiscence neighborhood Coordinators conduct rooms sweeps weekly to verify that there are no unsecured prescription medications. The Wellness nurses also do room sweeps during their monthly wellness visits and verify that there are no unsecured prescription medications. 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 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.