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: Yes

Areas Reviewed:

22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 6-20-2023, 1:01 ? 1:40 pm 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 3-15-2023 regarding allegations in the areas of Resident Care and Related Services and Additional Requirements for Facilities That Care for Adults with Serious Cognitive Impairments. Number of residents present at the facility at the beginning of the inspection: 76 The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Additional Requirements for Facilities That Care for Adults with Serious Cognitive Impairments. A violation notice was 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 #:	22VAC40-73-1070-A
Complaint related:	Yes
Description:	Based on record review and interview with staff, the facility failed to ensure when there are indications that ordinary objects may be harmful to a resident with a serious cognitive impairment, these objects shall be inaccessible to the resident except under staff supervision. Evidence: 1. Resident #1?s Progress Notes dated 4-14-2023 documented under Nurse Practitioner [NP] Note, ?Skin: skin around lips w/ some erythema, small healing nick area from shaving? Contact Dermatitis: to skin around lips from shaving?? 2. Additionally, Progress Notes dated 3-14-2023 documented, ??notified wellness resident [#1] observed with redness swelling to face where resident shaves, RP [responsible party] observed resident shaving his bare skin on face and attempted to shave [resident #1?s own] eyebrow, RP removed razor from residents room and brought it to wellness?? 3. Resident #1?s ISP dated 3-11-2023 documented under Grooming, ?Observe for and report any changes in my ability to perform grooming tasks? identified on 9-08-2021. Additionally under Housekeeping services, ?Hazardous materials will be kept secured to keep me safe?? 4. Staff #1 confirmed during interview that Resident #1 hadaccess to an electric razor that caused an injury above his lip and was ?under staff supervision? while using it.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-1110-A
Complaint related:	Yes
Description:	Based on record review and interview with staff, the licensee, administrator, or designee failed to determine whether placement in the special care unit is appropriate prior to admission a resident with a serious cognitive impairment in the safe, secure environment (SSE). The determination and justification for the decision shall be in writing and shall be retained in the resident's file. Evidence: 1. Resident #1?s Approval for Placement in the Special Care Unit was completed by the legal representative for the resident dated 3-10-2023 and the physician dated 3-08-2023. 2.There is no documentation of approval for placement in the SCU by the administrator or administrator?s designee.
Plan of Correction:	Not available online. Contact Inspector for more information.