VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sun Rise on the South Home Care and Transportation
3000 South Street
South chesterfield, VA 23834
(804) 605-7573

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: Aug. 13, 2024 and Aug. 16, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS

Comments:

Type of inspection: Complaint Dates of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/13/24 3pm to 5pm and 8/16/24 2:30p to 3:30 p The Acknowledgement of Inspection form was signed and left at the facility. A complaint was received by VDSS Division of Licensing on 8/5/24 regarding allegations in areas of: Administration and Administrative Services, Staffing and Supervision, Resident Care and Related Services, Personnel, Resident Accommodations and Related Provisions 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: 0 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication administration, postings, snacks, bedrooms, file documentation, staff/resident interaction 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: Administration and Administrative Services, Staffing and Supervision, Personnel, Resident Care and Related Services, Resident Accommodations and Related Provisions A violation notice was issued; any violations 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 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 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 Yvonne Randolph, Licensing Inspector at (804) 662-7454 or by email at yvonne.randolph@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-40-A
Complaint related:	Yes
Description:	Based on observation, the licensee failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department; with relevant federal, state, and local laws; with other relevant regulations; and with the facility's own policies and procedures. Evidence: The facility is licensed for seven residents, ten residents were observed in care on 8/13/24.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on receipt of an on-line complaint, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: On 8/4/24 a physical fight occurred inside the facility between the administrator/licensee and a male friend which required the intervention of local police. Ten residents were present during the fight. The incident exposed the residents to a potential risk of safety, health and welfare. The incident had not been reported as of 8/6/24.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-460-A
Complaint related:	Yes
Description:	Based on observation and interviews, the facility failed to ensure that the facility shall assume general responsibility for the health, safety, and well-being of the residents. Evidence: 1. The licensee had a male residing in the facility who was not a resident or staff person. The male did not have a tuberculosis screening or a background check. 2. The licensee was involved in a physical fight with the male while the residents were on site. 3. Staff # 2 was administering medications without the required qualifications.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-670-1
Complaint related:	No
Description:	Based on file reviews, 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. Evidence: The licensee reported that staff # 1 administers medications to the residents. There was no documentation to support that staff # 1 was authorized to administer medications. A copy of the letter approving staff # 1 to administer medications on a provisional status was not provided or in the file of staff # 1.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-860-C
Complaint related:	No
Description:	Based on observation, the facility failed to ensure that, before construction begins or contracts are awarded for any new construction, remodeling, or alterations, plans shall be submitted to the department for review. Evidence:The licensee converted one of the common areas into a resident bedroom, plans were not submitted to the department for review.
Plan of Correction:	Not available online. Contact Inspector for more information.