VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise on the South Home Care & Transportation
3000 South Street
South chesterfield, VA 23834
(804) 490-8899

Current Inspector: Yvonne Randolph (804) 441-1180

Inspection Date: April 10, 2025

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/10/25, 5 pm to 6:30 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 4/7/25 regarding allegations in the area of: Resident Care and Related Services and Administrative and Administration Services. Number of residents present at the facility at the beginning of the inspection: 10 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Resident files were not available for review. Number of staff records reviewed: Staff files were not available for review. Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 2 (licensee/administrator by telephone) Observations by licensing inspector: physical plant and medication administration records, dinner, meal preparations, postings Additional Comments/Discussion: A joint inspection was completed with a representative of local social services. The licensee/administrator was not on site An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; areas of non-compliance with standards or law were: Resident Care and Related Services A violation notice was issued; any violations not related to the 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 violations will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards 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 area s 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 Yvonne Randolph, Licensing Inspector at (804) 441-1180 or by email at yvonne.randolph@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-530-C
Complaint related:	No
Description:	Based on observation, the facility did not ensure freedom of movement for the residents to their personal space and that residents shall not be locked out of their rooms. Evidence: Resident # 1 stated during an interview that his bedroom is on the 2nd floor of the facility. During a inspection of the facility, it was observed that the door leading to the 2nd floor bedrooms was locked. Free access to the bedrooms is restricted as the key to the locked door is kept in the possession of the staff on duty.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-560-F
Complaint related:	No
Description:	Based on interviews, the facility did not ensure that all records shall be made available for inspection by the department?s representative. Evidence: Licensing staff requested resident records during an on-site inspection on 4/10/25. Staff # 1 informed licensing staff that the records were not available for review.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-670-1
Complaint related:	No
Description:	Based on a review of medication administration records and interviews, the facility did not ensure that each staff person who administers medication shall be authorized by ? 54.1-3408 of the Virginia Drug Control Act, i.e. be licensed by the Commonwealth of Virginia to administer medications or be registered with the Virginia Board of Nursing as a medication aide. Evidence: A review of medication administration records found that staff # 1 documented administering medications to nine residents on 4/9/25 and 4/10/25. Residents stated during interviews on 4/10/25 that staff # 1 administered their medications on 4/9/25 and 4/10/25. A n interview with staff # 2 and a review of the Virginia Board of Health Professions license lookup website confirmed that staff # 1 is not licensed by the Commonwealth of Virginia or registered as a medication aide with the Virginia Board of Nursing.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-H
Complaint related:	No
Description:	Based on documentation reviews, the facility did not ensure that at the time medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over the counter medications and dietary supplements. Evidence: The April 2025 medication administration record s found that facility staff did not document medication administered to nine residents(#1, 2, 3, 4, 5, 7, 8, 9,10) in the morning on April 2 to 5 and April 8-9 and in the evening on April 1-4 and April 7-8. One resident did not have a medication administration record for April 2025. This is a repeat violation cited previously at the 218/25 inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-A
Complaint related:	No
Description:	Based on observation, the facility did not ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. Evidence: One bedroom (1st floor at entrance) had a discolored floor and clothes in untidy piles scattered around the room. (Photo taken). A violation related to this standard was found and cited during a previous inspection on 1/28/25.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-E
Complaint related:	No
Description:	Based on observation, the facility did not ensure that all furnishings, fixtures and equipment shall be kept clean and in good repair and condition. Evidence: The closet in two of the 1st floor bedrooms was missing doors. The sofa in the upstairs common area had multiple fabric tears. There was a large opening in the wall of one 1st bedroom exposing pipes. (Photos taken)
Plan of Correction:	Not available online. Contact Inspector for more information.