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 20, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Technical Assistance:

Resident Council resolutions Length of activity time code Menu specifications

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: 6-20-2023, 9:00 a.m. ? 1:00 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: 76 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 Number of staff records reviewed:3 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 Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1110-B
Description:	Based on record review, the facility failed to ensure that six months after placement of the resident in the safe, secure environment (SSE) and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident's continued residence in the special care unit. Evidence: Resident #5 admitted to the SSE on 3-03-2021 according to the ?Review of Appropriateness of Continued Residence in Special Care Unit?. The last review in Resident #5?s record was documented as having been completed on 1-26-2022 and was due in January 2023.
Plan of Correction:	A. With respect to the specific resident/situation cited: Resident #5 continued special care placement form completed and placed resident file. B. With respect to how the facility will identify residents/situations with the potential for identified concerns: The ED or designee will audit all special care unit resident files to ensure proper documentation of continued placement for Special Care Unit is in place. C. With respect to what systemic measures have been put into place to address the stated concern: Current/New Reminiscence residents? approval for Placement in Special Care Unit forms will be reviewed by Resident Care Director or designee, prior to move in, 6 months and then annually. D. With respect to how the plan of correction will be monitored: ED will audit all new move ins and renewals for the next 3 months. 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 that a person?s physical examination contained a statement that specifies whether the individual is or is not capable of self- administering medication. Evidence: Resident #7 admitted 8-25-2022 to the facility. Resident #7?s Physicians Move in Orders dated 8-23-2022 documented six questions under ?Patient?s Ability to Self Medicate? including the question as to whether the resident is capable of self-administering medication, which was left unanswered by the physician who completed the form.
Plan of Correction:	A. With respect to the specific resident/situation: ED or designee has received an updated H & P from current physician for Resident #7 with all areas listed amened ?Patient?s Ability to Self-Medicate? including the question as to whether the resident is capable of self-administering medication, which was left unanswered by the physician who completed the form. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The ED will audit all new move in H & P?s for completion prior to move in. C. With respect to what systemic measures have been put in place to address the stated concerns: Upon a Resident moving in the DOS will review MI paperwork to ensure accurate and complete, ED or designee with review H & P as well to ensure accurate and complete. D. With respect to how the POC will be monitored: Over the next 3 months ED will audit all H & P?s for completion and accuracy and review result with Department heads in real time. Additional improvement plans will be implemented as necessary, including training to correct any deficient practices.
Standard #:	22VAC40-73-450-D
Description:	Based on record review and interview with staff, 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: Resident #7 admitted 8-25-2022. Resident #7?s ISP dated 2-28-2023 did not document hospice services; however, hospice notes in Resident #7?s record ranged from 2-22-2023 to 6-19-2023 and were ongoing at the time of inspection.
Plan of Correction:	A. With respect to the specific resident situation: Resident #7 ISP updated to include hospice provider & contact information with agreed upon plan of care. B. With respect to how the facility will identify residents/situations with the potential for identified concerns: The Assisted living and Reminiscence Coordinator will audit all residents receiving hospice services to confirm services are included on the ISP. C. With respect to what systemic measures have been put in place to address the stated concern: Upon a resident beginning Hospice service, the Resident Care Director or designee will update the ISP with information of the Hospice agency and services provided. Upon completion of updating the ISP the respective Care coordinator will review the ISP to verify it has been updated with the information of the Hospice Agency and services being provided. D. With respect to how the plan of correction will be monitored: During the Interdisciplinary team meeting and up to 3months following the implementation of the POC, the executive director will review the POC and the results of the audit with the department heads.
Standard #:	22VAC40-73-490-D
Description:	Based on record review and interview with staff, the facility failed to ensure the healthcare oversight included the specific residents for whom the oversight was provided must be identified. Evidence: Healthcare oversight documents dated 12-28-2022 and 6-12-2023 did not identify the residents reviewed for either oversight period. Staff #1 confirmed during interview that the residents reviewed were not identified with the healthcare oversights from either period.
Plan of Correction:	A. With respect to the specific resident/situation cited: Residents reviewed during the healthcare oversight period have been attached to oversight form. B. With respect to how the facility will identify resident/situations with the potential for the identified concerns: ED and RCD will include names of resident records reviewed during oversight period. C. With respect to what the systemic measures have been put into place to address stated concern: The Resident Care Director and ED will review healthcare oversight to ensure all standards are met. D. With respect to how the Plan of correction will be monitored: 6 months following the implementation of the POC ED will audit the HealthCare oversight.
Standard #:	22VAC40-73-750-C
Description:	Based on observation and interview with staff, the facility failed to ensure that a written specification that a resident does not wish to have an item listed in subsection B (a separate bed with comfortable mattress, springs, and pillow) was obtained. Evidence: Resident #1 was observed on 6-20-2023 as having a recliner in his room and no bed. Resident #1?s record did not contain documentation of a preference for not having a bed in the resident?s room.
Plan of Correction:	A. With respect to the resident/situation cited: ED/RCD reviewed ISP for Resident #1 and include his personal preference of having a recliner in place of bed. B. With respect to how the facility will identify residents/situation with the potential for identified concerns: The Assisted Living Coordinator and Reminiscence Coordinator will audit ISPs of residents with different sleeping accommodation preferences to ensure residents sleeping accommodation preferences are noted. C. With respect to what the systemic measures have been put into place to address stated concern: Upon a residents move in or change in required living accommodations; the community will update ISP with preferred accommodations. D. With respect to how the plan of correction will be monitored. During the monthly wellness visit the RCD or designee will audit residents? room for preferred sleeping accommodations.