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: June 15, 2022

Complaint Related: No

Areas Reviewed:

REVIEWED AREAS OF STANDARDS ? 22VAC40-73 GENERAL PROVISIONS ? 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES ? 22VAC40-73 PERSONNEL ? 22VAC40-73 STAFFING AND SUPERVISION ? 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS ? 22VAC40-73 RESIDENT CARE AND RELATED SERVICES ? 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS ? 22VAC40-73 BUILDINGS AND GROUND ? 22VAC40-73 EMERGENCY PREPAREDNESS ? 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ? ARTICLE 1 ? SUBJECTIVITY ? 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS ? 63.2 GENERAL PROVISIONS ? 63.2 PROTECTION OF ADULTS AND REPORTING ? 63.2 LICENSURE AND REGISTRATION PROCEDURES ? 63.2 FACILITIES AND PROGRAMS ? 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES ? 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION ? 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT ? 22VAC40-80 THE LICENSE ? 22VAC40-80 THE LICENSING PROCESS ? 22VAC40-80 COMPLAINT INVESTIGATION ? 22VAC40-80 SANCTIONS

Technical Assistance:

Approval for placement by administrator or designee completion Fire Drills times

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: 6/15/2022, 8:55 a.m. ? 2:35 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: 71 Number of resident records reviewed: 10 Number of staff records reviewed: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility, meals, activities, medication pass observation, emergency food and water. 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1100-C
Description:	Based on record review, the facility failed to document that the order of priority specified in subsection A of this section was followed, and the documentation shall be retained in the resident's file. Evidence: 1. The following three resident?s Approval for Placement in Special Care Unit forms were blank in the section, ?To be completed by assisted living facility. Explanation of why written approval was not obtained from each individual higher on the list of priority.?: a. Resident #1 (date of admission 3-29-2022), form on 3-24-2022; b. Resident #2 (date of admission 6-14-2021), form on 6-13-2021; and c. Resident #3 (date of admission 7-16-2019; form on 4-04-2022. 2. Staff #1 was not aware that it was required that the portion above was required to be filled in as part of the process and was not the staff member that had been previously completing the approval forms.
Plan of Correction:	A. With respect to the specific resident/situation cited: Resident #1,2 and 3?s Approval for Special Placement Forms were reviewed by the Executive Director and all forms were amended to include a response and explanation of why written approval was not obtained from each individual higher on the list of priority of the form. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Executive Director conducted an audit of Reminiscence resident?s Approval for Placement in Special Care Unit forms to confirm that the section, ?To be completed by assisted living facility. Explanation of why written approval was not obtained from each individual higher on the list of priority? was completed correctly. Any forms missing this section was updated accordingly and signed and dated with the date of the change. C. With respect to what systemic measures have been put into place to address the stated concern: All new Reminiscence resident?s Approval for Placement in Special Care Unit forms reviewed by the Resident Care Director or designee, prior to move in to confirm that the section, ?To be completed by assisted living facility. Explanation of why written approval was not obtained from each individual higher on the list of priority? was completed correctly. D. With respect to how the plan of correction will be monitored: During the QAPI meeting and up to 3 months following the implementation of the POC, the 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 the physical examination for residents contained the description of the person?s reactions to any known allergies. Evidence: 1. The following residents? ?Physician?s Move In Orders? that is the admitting physical examination form for the facility did not include the question regarding allergy reactions: a. Resident #1 admitted 3-29-2022. Resident #1?s physical examination form dated 3-15-2022 did not contain the question regarding allergy reactions. Resident #1 has no known allergies per the physical examination form. b. Resident #7 admitted 6-01-2022. Resident #7?s physical examination form dated 5-28-2022 did not contain the question regarding allergy reactions. Resident #1 has an allergy to sulfa per the physical examination form but no reaction listed. c. Resident #8 admitted 3-17-2022. Resident #8?s physical examination form dated 3-10-2022 did not contain the question regarding allergy reactions. Resident #8 has no known allergies per the physical examination form.
Plan of Correction:	A. With respect to the specific resident/situation cited: The physicians for residents #1, 7 and 8 were notified by the Executive Director of the ?Physician?s Move in Orders? (physical examination forms) did not include the question regarding allergy reactions. The physicians provided the responses, and the forms were updated. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: An audit was conducted of all residents physical examination forms to verify they are complete and include the question regarding allergy reactions and response if applicable. Any forms missing allergy reaction question and/or responses will be communicated with the respective physician for updating. C. With respect to what systemic measures have been put into place to address the stated concern: The process for reviewing physical examination forms upon receipt for complete responses to all required fields and questions was reviewed with the nursing staff. The Director of Sales, Resident Care Director and Wellness Nurses have been in serviced on reviewing physical examination forms upon receipt for complete responses to all required fields and questions. The Resident Care Coordinator or designee reviews new admission physical examination forms to verify the form is complete with responses to all required fields and questions. D. With respect to how the plan of correction will be monitored: During the QAPI meeting and up to 3 months following the implementation of the POC, the 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 #:	22VAC40-73-350-B
Description:	Based on record review, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days and shall document in the resident's record that this was ascertained and the date the information was obtained. Evidence: 1. Resident #8 moved into the facility on 3-17-2022 under respite initially per his progress notes. The resident remained in the facility until hospitalization on 4-22-2022, and returned to the facility on 4-25-2022 to stay. The sex offender screening for the resident wasn?t completed until 6-15-2022.
Plan of Correction:	A. With respect to the specific resident/situation cited: No negative outcome occurred related resident # 8?s sex offender registry paperwork. Resident #8?s sex offender screening was completed on 6/15/22. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: An audit is being conducted by the Executive Director to verify each resident has dated documentation in their record to indicate that a search was completed to ascertain whether a potential resident is a registered sex offender. C. With respect to what systemic measures have been put into place to address the stated concern: The Director of Sales has been retrained on the expected process to follow and proper documentation that the search was completed in a resident?s record. The Executive Director will review new resident records to verify each resident has dated documentation in their record to indicate that a search was completed to ascertain whether a potential resident is a registered sex offender. D. With respect to how the plan of correction will be monitored: During the QAPI meeting and up to 3 months following the implementation of the POC, the 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 #:	22VAC40-73-410-A
Description:	Based on record review, the facility failed to ensure orientation was provided upon admission to new residents and their legal representatives. Evidence: 1. Resident #8 admitted 3-17-2022. The resident?s orientation was not completed until 5-03-2022 per the resident?s record.
Plan of Correction:	A. With respect to the specific resident/situation cited: Resident #8?s orientation was conducted and placed in resident?s file. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: An audit was conducted to verify there is documentation that orientation was provided upon admission to new residents and their legal representatives. C. With respect to what systemic measures have been put into place to address the stated concern: All new resident orientation will be conducted by the admitting nurse or designee upon arrival, during physical and vitals check. The resident will sign an orientation form and the admitting nurse/designee will provide the Director of Sales with the signed form to file in the resident?s business record. The Executive Director or designee will review the orientation documentation within 24 hours of move-in for new residents to verify it was completed. D. With respect to how the plan of correction will be monitored: During the QAPI meeting and up to 3 months following the implementation of the POC, the 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 #:	22VAC40-73-960-B
Description:	Based on observation, the facility failed to ensure the fire and emergency evacuation drawing showed primary and secondary escape routes, areas of refuge, assembly areas, and fire alarm boxes. Evidence: 1. Photographic evidence obtained on 6-15-2022 documented the facility fire and emergency evacuation drawing documented ?exit?, ?telephone?, and ?fire extinguisher?. No primary and secondary routes were identified, nor was the areas of refuge, assembly areas, and fire alarm boxes.
Plan of Correction:	A. With respect to the specific resident/situation cited: The facility fire and emergency evacuation drawing has been updated to include the primary and secondary evacuation route, as well as areas of refuge, assembly areas, and fire alarm boxes. The new document has been posted. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Maintenance Coordinator has inspected all Emergency Evacuation drawings to verify all drawings include primary and secondary escape routes, areas of refuge, assembly areas, and fire alarm boxes. C. With respect to what systemic measures have been put into place to address the stated concern: Annually the Maintenance Coordinator will review the regulatory requirements for emergency evacuation drawing and verify changes to the drawings are not required. If so, the drawing will be updated to meet regulatory requirements and re-posted. Training will be provided to team members as needed. The Executive Director will add to the Quality Assurance and Performance Improvement (QAPI) meeting agenda the need to review the emergency evacuation drawings annually and confirm the posted drawings meet regulatory requirements. D. With respect to how the plan of correction will be monitored: During the QAPI meeting and up to 3 months, the Executive Director and Department Heads will review the Plan of Correction (POC) to verify implementation. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
Standard #:	22VAC40-90-30-C
Description:	Based on record review, the facility failed to ensure staff persons did not make a materially false statement on the sworn statement or affirmation. Evidence: 1. Staff #5?s date of hire was 1-31-2022. Staff #5?s Sworn Statement was not dated and stated ?No? for the question, ?Have you ever been convicted of a law violation(s) but excluding offenses committed before your eighteenth birthday that were finally adjudicated in a juvenile court or under a youth offender law?? however, the staff?s Criminal History Request Response dated 1-12-2022 documented a conviction. 2. Staff #6?s date of hire was 4-19-2022. Staff #6?s Sworn Statement dated 3-30-2022 and stated ?No? for the question, ?Have you ever been convicted of a law violation(s) but excluding offenses committed before your eighteenth birthday that were finally adjudicated in a juvenile court or under a youth offender law?? however, the staff?s Criminal History Request Response dated 4-05-2022 documented a conviction.
Plan of Correction:	A. With respect to the specific resident/situation cited: The sworn statements and background checks for team members 5 and 6 were reviewed. Team members # 5 and 6 have completed Sworn Disclosures to include convictions, signed and dated with the date of the change. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Executive Director has conducted an audit of team member Sworn Disclosure Statements and VA State Police Background Results to verify staff persons did not make a materially false statement on the sworn statement or affirmation and for the form is dated. C. With respect to what systemic measures have been put into place to address the stated concern: Upon hire of a new employee the Business Office Coordinator will review Sworn Disclosure Statements or affirmation and the VA State Police Background results to verify the new employee did not make a materially false statement on the sworn statement or affirmation and for the form is dated. The Executive Director will audit new team member files for the next three months to verify the new employee did not make a materially false statement on the sworn statement or affirmation and for the form is dated. D. With respect to how the plan of correction will be monitored: During the QAPI meeting and up to 3 months following the implementation of the POC, the 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.