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: Nov. 7, 2022

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 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

Comments:

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/07/2022 9:00am until 4:00pm 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: 157 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 23 Number of staff records reviewed: 8 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-C-2
Description:	Based on observation and document review, the facility failed to implement their infection control policy regarding blood glucose monitoring practices. EVIDENCE: 1. The facility?s infection control policy and procedures, page 2, states the following: ?All residents must have their own glucometer if they require monitoring. Their name MUST be labeled on EACH piece of equipment ? glucometer, outside of the kit etc.? 2. At 10:08 AM, while performing an audit of the medication cart for the 3rd floor with staff 1, an unlabeled glucometer inside of the bag labeled for resident 13 was observed. In addition, an unlabeled bag was observed that also contained an unlabeled glucometer. Staff 1 stated that this unlabeled bag and unlabeled glucometer belonged to resident 14.
Plan of Correction:	The facility Administrator or Designee will ensure all blood glucose monitoring equipment is properly labelled with the resident?s name.
Standard #:	22VAC40-73-325-B
Description:	Based on a review of resident records, the facility failed to ensure that a fall risk rating was completed every time a resident assessed as assisted living level of care had a fall. EVIDENCE: 1. The record for resident 9, who is assisted as assisted living level of care their uniform assessment instrument (UAI) dated 05/23/2022, has documentation of the resident falling on 09/18/2022 and 09/28/2022. The record for resident 9 did not contain documentation of a fall risk rating being completed for these falls. 2. The record for resident 11, who is assisted as assisted living level of care their UAI dated 06/11/2022, has documentation of the resident falling three times on 09/18/2022. The record for resident 11 did not contain documentation of a fall risk rating being completed for these falls.
Plan of Correction:	The Fall Risk Rating Tool will be completed after each resident fall.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure the individualized service plan (ISP) contained all required components. EVIDENCE: 1. The ISP for resident 7, updated 09/21/2022, contained documentation that the resident receives home health (wound care) three times a week and as needed to the resident?s left lower extremity (LLE); however, a physician?s order, dated 10/27/2022, indicated that the wound care to the resident?s LLE had been discontinued because the wound had healed. The ISP had not been updated to reflect that the resident is no longer receiving wound care. 2. The record for resident 9 has documentation of a physician order dated 10/21/2022 for foley catheter and catheter care every shift, empty and record output every shift. The ISP for resident 9, dated 05/23/2022, is inconsistent as it has documentation of foley catheter care to be completed PRN (as needed).
Plan of Correction:	The comprehensive individualized service plan will identify the resident needs, the ISP will be updated as needed to ensure services for the resident are up to date.
Standard #:	22VAC40-73-640-A
Description:	Based on observation and record review, the facility failed to implement its medication management plan (MMP) with regards for monitoring to prevent outdated medications, the timely re-ordering of resident medications, and ensuring accurate counts of all controlled substances whenever medication administration staff changes. EVIDENCE: 1. The third floor medication cart contained Lantus insulin pens for residents 15 and 16. An interview with staff 1 expressed that they were not sure if the insulin pens had been opened or how long they had been stored on the cart. Manufacturers instructions are to store unopened Lantus pens in the refrigerator. The pens did not contain any dates to indicate that they were open. The facility MMP has documentation that states that medication carts will be audited randomly by the administrator or designee on alternating shifts as a method to prevent the use of outdated medications. 2. During a cart audit of medications for resident 14, it was observed that the prescribed medication Aspirin EC 325mg, 1 tablet by mouth daily for 14 days for DVT prophylaxis was not available in the cart for resident 14. Interview with staff 1 indicated that they had to request a refill on the morning of the inspection because the medication was out. Staff 1 also admitted that resident 14 did not receive his 9:00 AM dose of Aspirin on the date of inspection since it unavailable, which was indicated on the MAR for the morning of inspection. The facility?s MMP states that to ensure that each resident?s prescription medications are refilled in a timely manner to avoid missed dosages, the facility will fax refill requests to the pharmacy at least 48 hours in advance. 3. While performing an audit of the medication cart for the 3rd floor with staff 1, it was observed that resident 17 was prescribed Gabapentin CV 300mg capsules, which is a controlled substance. The narcotic count log book has documentation of 36 capsules of Gabapentin CV 300mg for resident 17 that were counted and signed for on the morning of the inspection by the oncoming and off going medication staff. Upon review of the corresponding pill pack for that medication count, the actual count on the cart was 37 Gabapentin CV 300mg capsules in the pack. The facility?s MMP indicates that to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes, the RMA/LPN will count narcotics with oncoming/off going shift and document in narcotic log record, and a signature is required by both RMAs/LPN per shift.
Plan of Correction:	The facility will follow the medication management plan. The Administrator/Designee will ensure the medication management plan is followed.
Standard #:	22VAC40-73-660-B
Description:	Based on observation during a tour of the facility?s physical plant and resident record review, the facility failed to ensure that for residents with medications in their rooms the uniform assessment instrument (UAI) indicated the residents are capable of self-administering medication. EVIDENCE: 1. The UAI for resident 7, dated 04/28/2022, indicated that the resident requires medication to be administered/monitored by a lay person. The following medications were found in the resident?s room during on-site inspection: a bottle of Dayquil severe cold and flu, a bottle of Nyquil severe cold and flu, a bottle of allergy relief nasal spray, a bottle of Ibuprofen PM, a bottle of Phillips? milk of magnesia, two containers of Tum antacid, and a bottle of Hydrogen Peroxide. The record for resident 7 did not contain physicians? orders that the resident may self-administer the aforementioned medications. 2. The UAI for resident 21, dated 10/17/2022, indicated that the resident requires medication to be administered/monitored by a lay person. The following medications were found in the resident?s room during on site-inspection: a bottle of Miralax and a bottle of Refresh optive advanced eye drops. The record for resident 21 did not contain physicians? orders that the resident may self-administered the aforementioned medications. 3. The UAI for resident 4, dated 07/23/2022 indicated that the resident requires medication to be administered/monitored by a lay person. A Ventolin HFA 90mcg inhaler with a manufacturer expiration date of 03/2021 was observed sitting out in the room for resident 4. The record for resident 4 did not contain physician orders that the resident could self-administer this medication.
Plan of Correction:	Residents who are capable of self-administration of medications shall keep his own medications in an out of sight place in his room. The medications will be stored so that they are not acceptable to other residents.
Standard #:	22VAC40-73-680-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that medications are administered by staff who are licensed, registered, or acting as medication aides on a provisional basis for residents who are dependent on medication administration as documented on the uniform assessment instrument (UAI). EVIDENCE: 1. The UAI for resident 3, dated 08/31/2022, indicated that the resident requires medication to be administered/monitored by a lay person; however, the UAI includes documentation that the resident?s wife administers all of resident 3?s medications. The resident?s wife, who is also a resident of the facility (resident 1), is not a staff member who is licensed, registered or acting on a provisional basis to be able to administer medications. Interviews with staff 2 and 7 confirmed that resident 3?s wife does administer the resident?s medications. 2. The UAI for resident 5, dated 10/11/2022, indicated that the resident requires medication to be administered/monitored by a lay person; however, the UAI includes documentation that the resident?s wife administers all of resident 5?s medications. The resident?s wife, who is also a resident of the facility (resident 6), is not a staff member who is licensed, registered or acting on a provisional basis to be able to administer medications. Interviews with staff 2 and 7 confirmed that resident 5?s wife does administer the resident?s medications.
Plan of Correction:	RMAs/Provisional RMAs will ensure medications are administered to those residents who are dependent for medication admission as documented on the UAI.
Standard #:	22VAC40-73-680-B
Description:	Based on observation during a tour of the facility?s physical plant and resident record review, the facility failed to ensure medications remained in the pharmacy issued container until administered to the resident. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 22, dated 10/24/2022, indicated that the resident requires medication to be administered/monitored by a lay person. During the on-site inspection, one licensing inspector (LI) observed the following pills on the resident?s floor beside his bed: a small, white square pill with ?60? and ?CC?, two small red pills, and a small, white round pill. The aforementioned pills were also observed by staff 7. During an interview with resident 22 it was confirmed that the four pills found on the floor were his. 2. A white oblong pill labeled with ?L544? was observed in the presence of staff 1 in the bottom of the second drawer of the third floor medication cart.
Plan of Correction:	Medications will remain in the pharmacy issued container until administered to the resident. RMA will ensure medications have been swallowed before exiting the resident room. An in-service will be conducted with all RMAs.
Standard #:	22VAC40-73-860-I
Description:	Based on observation during a tour of the facility?s physical plant, the facility failed to ensure cleaning supplies were stored in a locked area. EVIDENCE: 1. At approximately 10:21AM, one licensing inspector (LI) observed a spray can of Citrus Fresh surface disinfectant spray in an unlocked cabinet in the second floor day room. This was also observed by staff 2. 2. A can of Shurfine Antibacterial Spray was observed sitting out on the dresser in room 144. The door to the room was unlocked and the room was unattended. 3. A container of Sani-Cloth Germicidal Wipes was noted to be sitting out on the bathroom shelf in room 140. The door to the room was unlocked and the room was unattended.
Plan of Correction:	The facility will store cleaning supplies and other hazardous materials in a locked area. Routine rounds will be made by Administrator or designee to ensure chemicals/cleaning agents are secured from resident access.
Standard #:	22VAC40-73-870-A
Description:	Based on observation during a tour of the facility?s physical plant, the facility failed to ensure that the interior of the building was kept clean. EVIDENCE: 1. At approximately 9:53AM, one licensing inspector (LI) observed the toilet in resident 22?s bathroom to have multiple brown stains on the inside of the toilet bowl. This was also observed by staff 7. 2. At approximately 10:17AM, one LI observed the mattress cover on the mattress on resident 7?s bed to have multiple staining. 3. At approximately 9:48AM, one LI observed a used blood glucose test strip on the floor outside of room 227. This was also observed by staff 2. 4. The vents in the ceil of the kitchen were noted to be dusty/dirty on the day of inspection. 5. A ceiling stain was noted in the hallway outside of the therapy room on the second floor.
Plan of Correction:	The interior and exterior of the facility will be maintained, clean and free of rubbish. Resident sheets will be changed routinely as care is performed and/or linens are soiled. Resident room will be cleaned routinely to include bathroom toilet. RMAs will secure all used glucometer testing strips in the provided sharps container on each medication cart. The kitchen vents will be placed on a routine schedule for cleaning to ensure they are free of dirty/mold/rubbish. Soiled top sheet, soiled toilet and diabetic testing strip ? corrected on date of inspection Soiled kitchen vents ? date of correction 12/15/2022
Standard #:	22VAC40-73-870-B
Description:	Based on observation during a tour of the facility?s physical plant, the facility failed to ensure the building was free of foul, stale and musty odors. EVIDENCE: 1. Upon entering residents? 22 and 23 room, one licensing inspector (LI) noted a foul and stale odor. This odor was also noted by staff 7.
Plan of Correction:	The facility will be free of foul, musty or stale odors. Housekeeping will clean resident rooms and common areas as scheduled and as needed to ensure the facility is free of foul odors