VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Runk and Pratt at Liberty Ridge
30 Monica Blvd.
Lynchburg, VA 24502
(434) 237-2268

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: Sept. 27, 2021

Complaint Related: No

Areas Reviewed:

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 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:

To ensure the facility had a thorough understanding of the standards, the licensing inspector and the Administrator had a discussion regarding standards 22VAC40-90-30 B, 250-D, 290-A and 550-G.

Comments:

A renewal inspection was initiated on 09/27/2021 and concluded on 09/28/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 172. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 5 resident records, 5 staff records, current activities calendar, current menu, staff schedule, recent health care oversight, recent health department and fire inspections, fire drill dates/shifts for the past year and recent dietitian review submitted by the facility to ensure documentation was complete. The inspector conducted a virtual inspection with the Administrator of the physical plant and medication carts on 09/28/2021. An exit interview was conducted with the Administrator on 09/28/2021, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure residents' individualized service plans (ISP) included all required components. EVIDENCE: 1. The record for resident 1 contained a physician's order, dated 07/17/2021, for "restart Unna boots to B LE - open area's weeping - 2x wk + prn - done by hospice". The ISP for resident 1, updated 07/17/2021, does not include this treatment being provided by hospice. The ISP for resident 1, with an identified need date of 03/10/2021, and the ISP for resident 2, with an identified need date of 03/03/2021, showed that resident 1 and 2 have "pain management - monitor pain control with meds. Alert MD when ineffective" and "psychotropic medications - Administer as ordered by MD if increased drowsiness, decreased functional ability, increased aggression, or isolation"; however, the ISPs for residents 1 and 2 do not indicate what medications are prescribed to the residents. The ISP for resident 2, with an identified need date of 03/03/2021, and resident 3, with an identified need date of 04/23/2021, showed the following for resident 2 and 3: "Resident able to consume alcohol per MD orders"; however, the ISPs for resident 2 and 3 do not indicate what the physician's order is.
Plan of Correction:	Administrator/Designee will ensure the resident's ISP clearly reflects all required components.
Standard #:	22VAC40-73-640-A
Description:	Based on document review, the facility failed to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The facility's current medication management plan, "Runk and Pratt @ Liberty Ridge Medication Management Plan", states "A narcotic log is completed by off-going and on-coming RMAs/LPN and a signature is required by both RMAs/LPN per shift." 2. The "Narcotic Count/Key Transfer Sheet" for September 2021 for "Wing: AL1" does not contain the signature of the medication staff for 09/18/2021 for "oncoming 11-7 RMA". The "Narcotic Count/Key Transfer Sheet" for September 2021 for "Wing: Orchards" does not contain signatures of the medication staff for the following dates: "Oncoming 7-3 RMA" - 09/05-06/2021, 09/08/2021, 09/12/2021 and 09/18-19/2021; "Outgoing 7-3 RMA" - 09/05-06/2021, 09/08/2021, 09/12/2021 and 09/18-19/2021; "Oncoming 3-11 RMA" - 09/01/2021, 09/05/2021, 09/10/2021, 09/15/2021 and 09/25-26/2021; "Outgoing 3-11 RMA" - 09/01/2021, 09/05/2021, 09/10/2021, 09/15/2021, 09/18/2021 and 09/25-26/2021; and "Oncoming 11-7 RMA" on 09/18/2021.
Plan of Correction:	Runk and Pratt will follow the current medication management plan. The narcotic log will be completed with off-going and on-coming RMA/LPN to include signature of completion.
Standard #:	22VAC40-73-680-E
Description:	Based on resident record review and virtual inspection, the facility failed to ensure medical procedures or treatments ordered by a physician were provided according to his instructions. EVIDENCE: 1. The record for resident 2 contained a physician's order, dated 04/01/2021, for "Protective boots to be worn at all times on both feet while in bed for skin integrity". The September 2021 medication administration record (MAR) showed that at the time "AM" on 09/04/2021 and 09/18/2021 and at the time "PM" on 09/03/2021 and 09/05/2021 that the resident was in bed; however, staff documented that the resident did not have her protective boots on. The record for resident 2 contained a note from Collateral 1,dated 09/08/2021, that stated "Protective boots were not on at this time, so nurse and facility staff put boots back on and staff verbalized understanding that boots are to be worn at all times while patient is in bed." During virtual inspection with staff 6 on 09/28/2021 at approximately 9:46 AM resident 2 was observed laying in bed and did not have her protective boots on.
Plan of Correction:	All physician's orders to include instructions will be followed by RMA/LPN regarding treatments and/or procedures.
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review, the facility failed to ensure a valid physician's order for oxygen contained all the required components. EVIDENCE: 1. The record for resident 1 contains a physician's order, dated 09/22/2021, that showed "Oxygen- as needed- 1- Administer oxygen at 2LPM via nasal cannula as needed as needed for SOB/respiratory distress - PRN indicated for SOB". The order does not contain the oxygen source.
Plan of Correction:	Physician orders regarding oxygen therapy will contain all required components.
Standard #:	22VAC40-73-980-H
Description:	Based on virtual inspection and staff interview, the facility failed to ensure there was at least 48 hours of water supply on site. EVIDENCE: 1. On the day of virtual inspection the facility census was 172. Staff 6 indicated that there was only 28 gallons of water on site. The Virginia Department of Emergency Management recommends one gallon of water per day for each resident and staff member which would require at least 344 gallons of water on site on the day of inspection to have a 48 hour supply.
Plan of Correction:	Administrator/Designee will ensure the facility maintains at least 48 hours of water supply on site at all times.