VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise of Richmond
1807 N. Parham Road
Richmond, VA 23229
(804) 967-0303

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: Feb. 23, 2022

Complaint Related: Yes

Areas Reviewed:

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

Comments:

A complaint investigation regarding the areas of admission, retention and discharge of residents, resident care and related services, and staffing/staff training was conducted. The inspection was conducted onsite on February 23, 2022 from 3:10 p.m. to 4:23 p.m. and concluded March 22, 2022 by phone. The Administrator and Director of Nursing were present onsite for inspection. Resident records and staff records were reviewed, as well as staff interviews conducted. There were violations found in the areas of administration and administrative services and resident care and related services.

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on record review and interview with staff, 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: 1. Resident #1 had the following incidents noted in the Progress Notes of the record; however, the central regional licensing office did not receive reports of these incidents: a. 12-05-2021 12:22 [p.m.]: ?Went in another resident room and got in bed with [resident] and tried to push [resident] out the bed when cm tried to get [Resident #1] out of the bed [Resident #1] was kicking and hitting [resident]?. b. 11-30-2021 7:37 [a.m.]: ?Resident [#1] smacked another resident in the face.? c. 11-07-2021 11:24 [a.m.]: ?[Resident #1] Pushed another resident today as [resident] was trying to enter [resident?s] room?? 2. Staff #1 confirmed the facility failed to report the aforementioned incidents involving Resident #1?s major incidents that negatively affected the life, health, safety or welfare of any resident.
Plan of Correction:	A. With respect to the specific resident/situation cited: Resident Care Director, Reminiscence Coordinator, Wellness Nurses and Manager?s on Duty received counseling/education on reporting requirements within 24-hours and the process in which to submit the report. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Department Head Team reviewed all clinical alerts and incident reports, and will review the previous 24-hours during the morning Stand-up Meeting daily, moving forward. During this review the team will identify any occurrence that are required to be reported and submit report by end of that day. C. With respect to what systemic measures have been put into place to address the stated concern: The Executive Director, Resident Care Director, or Designee have implemented the above procedure and will review the effectiveness of the process each month for 3 months to confirm on-going compliance with reporting requirements. D. With respect to how the plan of correction will be monitored: The Executive Director or designated Coordinator is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur. During and at the end of the 3 months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results and determine if additional focus or action is warranted.
Standard #:	22VAC40-73-440-A
Complaint related:	Yes
Description:	Based on record review and interview with staff, the facility failed to ensure the uniform assessment instrument (UAI) was updated whenever there was a significant change in the resident's condition. Evidence: 1. Resident #1?s individualized service plan (ISP) was updated 9-10-2021 and 9-20-2021 with the following changes: Added ?elopement risk/wanders/exit seeking, disruptive behaviors, physically aggressive- beating walls, doors and windows with hands?. Resident #1?s UAI dated 5-08-2021 did not address the change in resident?s condition and documented resident?s Behavior Pattern as ?Appropriate?. 2. Resident #2?s ISP was updated 9-07-2021 with the following changes: ??fall with actual injury? (remind to use wheelchair and not to walk)?. Resident #2?s UAI dated 5-19-2021 did not address the change in resident?s condition and documented resident?s Ambulation as ?Wheeling: Is Not Performed?. 3. Neither Resident #1 nor Resident #2?s UAI?s were updated with the aforementioned information to address the significant changes in the residents? conditions.
Plan of Correction:	A. With respect to the specific resident/situation cited: The Resident Care Director and Reminiscence Coordinator unable to make corrections since both residents no longer reside at the community. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Resident Care Director and Reminiscence Coordinator or designee have begun an audit of resident UAI?s to confirm they reflect the needs for care and behaviors for each resident. C. With respect to what systemic measures have been put into place to address the stated concern: The Resident Care Director, Reminiscence Coordinator or Designee will review UAI?s each month for 3 months to confirm they reflect the needs for care of each resident. During and at the end of 3 months, the leadership team will evaluate the results of the UAI reviews and determine if additional focus or action is warranted during Monthly Quality Assurance and Performance Improvement (QAPI) meetings. D. With respect to how the plan of correction will be monitored: The Executive Director or designated Coordinator is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur. During and at the end of the 3 months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results and determine if additional focus or action is warranted.
Standard #:	22VAC40-73-450-F
Complaint related:	Yes
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?s legal representative including reviews and updates of the plan. Evidence: 1. Resident #1?s ISP contained reviews/updates on the following service needs and dates after the ISP dated and signed by the resident?s legal representative on 5-11-2021: a. Inability to use signaling device with need for night safety checks (9-10-2021), b. Pain (8-30-2021), c. Impaired/Limited Vision (9-10-2021), d. Impaired Hearing (9-10-2021), e. Impaired cognitive function related to my early on set Alzheimer?s (9-10-2021), Nutritional Risk (9-10-2021), f. Bowel continence (9-10-2021), g. Fractured left wrist (7-11-2021), h. Fall risk factors (9-27-2021, 10-09-2021), i. elopement risk/wanders/exit seeking (9-10-2021), j. Disruptive behaviors (9-10-2021), and k. Physically Aggressive ? Beating walls, doors and windows with hands (9-20-2021), Hospice Services (8-09-2021). 2. Resident #2?s ISP contained reviews/updates on the following service needs and dates after the ISP dated and signed by the resident?s legal representative on 5-24-2021: a. Fall risk factors (8-27-2021, 9-04-2021), and b. Fracture of left clavicle (9-07-2021). 3. Staff #1 confirmed during interview the facility failed to ensure the ISP was signed and dated for Resident #1 and Resident #2?s legal representatives including reviews and updates of the plans.
Plan of Correction:	A. With respect to the specific resident/situation cited: The Resident Care Director and Reminiscence Coordinator unable to make corrections since both residents no longer reside at the community. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Resident Care Director, Reminiscence Coordinator or designee have begun an audit of the ISPs to confirm they reflect the preferred and required personal grooming, hygiene, and special care and behavioral interventions for each resident. C. With respect to what systemic measures have been put into place to address the stated concern: The Resident Care Director, Reminiscence Coordinator or Designee will review ISPs each month for 3 months to confirm ISPs reflect the preferred and required care for each resident. During and at the end of 3 months, the leadership team will evaluate the results of the ISP reviews and determine if additional focus or action is warranted. The leadership team will evaluate the results of the ISP reviews and determine if additional focus or action is warranted during Monthly Quality Assurance and Performance Improvement (QAPI) meetings. D. With respect to how the plan of correction will be monitored: The Executive Director or designated Coordinator is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur. During and at the end of the 3 months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results and determine if additional focus or action is warranted.