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: March 17, 2023

Complaint Related: No

Areas Reviewed:

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

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/17/2023 8:45am until 2:30pm 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: 183 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 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 approximately 10:02AM, one licensing inspector (LI) along with staff 4 observed a black glucometer bag labeled with resident 3?s name in the Laurel?s medication cart on the second floor; however, the glucometer that was inside of the bag contained resident 4?s name.
Plan of Correction:	? Facility will ensure that according to the infection policy: ? All residents will have their own glucometer if they require monitoring ? Their name will be labeled on each piece of equipment ? glucometer, outside the kit
Standard #:	22VAC40-73-640-A
Description:	Based on observation and resident record review, the facility failed to implement its medication management plan (MMP) with regard for monitoring to prevent outdated medications. EVIDENCE: 1. The second-floor medication contained a Levemir insulin pen for resident 3 that had been opened. The pen did not include a date of when it was opened by staff. Manufacturer?s instructions indicate that Levemir expires 42 days after it is opened. This was also observed by staff 4. 2. The March 2023 medication administration record (MAR) for resident 9 contains documentation that the resident receives Lantus and Humalog insulin daily. The second-floor medication cart contained an opened Lantus insulin pen and an opened Humalog insulin pen in a zip-lock bag along with the resident?s glucometer. Neither pen included a date of when the insulin pens were opened by staff. Manufacturer?s instructions indicate that both insulins expire 28 days after they are opened. This was also observed by staff 4. 3. The facility?s MMP contains 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.
Plan of Correction:	? Facility will ensure that all medication ? specifically insulin has an open date written on each pen ?Facility will ensure that medication carts are audited randomly by administrator or designee on alternating shift as a method to prevent the use of outdated medication.
Standard #:	22VAC40-73-660-B
Description:	Based on observation during a tour of the building 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 and the medication shall be stored so they are not accessible to other residents. EVIDENCE: 1. The UAI for resident 5, dated 10/17/2022, indicates that the resident requires medication to be administered/monitored by a lay person. A container of Miralax on the counter in resident 5?s room was observed by one licensing inspector (LI) during on-site inspection on 03/17/2023. The record for the resident does not contain a physician?s order that the resident may have this in his room and self-administer Miralax. 2. The UAI for resident 6, dated 01/25/2023, indicates that the resident requires medication to be administered/monitored by a lay person. A container of Equate milk of magnesia in the bathroom in resident 6?s room was observed by one LI during on-site inspection 03/17/2023. The record for the resident does not contain a physician?s order that the resident may have this in her room and self-administer milk of magnesia. 3. The UAI for resident 7, dated 09/03/2022, indicates that the resident requires medication to be administered/monitored by a lay person. During on-site inspection on 03/17/2023, one LI and staff 1 observed that the resident had a container of Equate hydrocortisone cream, Equate nasal spray, eye drops, and a container of Robitussin cough medicine sitting in the chair beside the resident?s bed. The record for the resident does not contain physicians? orders that the resident may have the aforementioned medications in his room and self-administer them. 4. At approximately 9:33AM, one LI noted that the door to resident 2?s room was unlocked and unattended. On top of the dresser in the resident?s bedroom contained a container of Kroger extra strength acetaminophen and a container of Equate nasal spray. The record for the resident does not contain a physician?s order that the resident may have in his room extra strength acetaminophen and self-administer. The resident does have a physician?s order that he can have and self-administer the nasal spray; however, it is not being stored so that it is not accessible to other residents.
Plan of Correction:	? Facility will ensure that residents with medication in their room (according to their UAI) are capable of administering and that their medications will be stored so they are not accessible to other residents ? Medication not ordered by a medical professional will not be self-administered ? All over the counter medications will have an order from a medical professional
Standard #:	22VAC40-73-680-A
Description:	Based on observation and resident record review, 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 7, dated 09/30/2022, indicates that the resident requires medication to be administered/monitored by a lay person; however, during on-site inspection on 03/17/2023, one licensing inspector (LI) observed resident 7?s wife putting eye drops in the resident?s eyes. The resident?s wife, who is also a resident of the facility, is not a staff member who is licensed, registered or acting on a provisional basis to be able to administer medications.
Plan of Correction:	? Facility will 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 administrations as documented on UAI.
Standard #:	22VAC40-73-680-B
Description:	Based on observation during a tour of the building, the facility failed to ensure medications remained in the pharmacy issued container until administered to residents. EVIDENCE: 1. At approximately 10:05AM, one licensing inspector (LI) observed a small round, white pill inscribed with ?17? on the floor outside of room 206. Also, the same LI observed a small round, dark red pill on the floor outside of room 216. These pills were also observed by staff 4. 2. At approximately 10:15AM, one LI observed a plastic clear cup that contained a small white, oblong pill the trash bin on the side of a medication cart on the third floor. Staff 3 had possession of the keys to this medication cart.
Plan of Correction:	? Facility will ensure that medications will remain in the pharmacy issued container until administered to residents
Standard #:	22VAC40-73-860-D
Description:	Based on observation during a tour of the building, the facility failed to ensure that operable windows were effectively screened. EVIDENCE: 1. 2 operable windows in the fitness room did not have screens on the day of inspection. 2. 2 operable windows in the McIntosh room did not have screens on the day of inspection. 3. 2 operable windows in the room across from the McIntosh room did not have screens on the day of inspection. 4. 8 operable windows in the IL and AL dining rooms did not have screens on the day of inspection.
Plan of Correction:	? Facility will ensure that all operable windows are effectively screened
Standard #:	22VAC40-73-860-I
Description:	Based on observation during a tour of the building, the facility failed to ensure cleaning supplies and other hazardous materials were stored in a locked area. EVIDENCE: 1. At approximately 9:14AM, one licensing inspector (LI) observed a spray bottle of Medline skintegrity wound cleanser, a spray can of Tresemme hairspray and a bottle of mouthwash in the bathroom in resident 1?s room. The door to the room was unlocked and the room was unattended. 2. At approximately 9:28AM, two LIs observed a container of Member?s Mark disinfecting wipes located in a bottom cabinet along the wall in the Pratt Chapel. 3. At approximately 9:32AM, one LI observed a spray bottle of Spray N Wash and a container of All laundry detergent in resident 2?s bathroom. The door to the room was unlocked and the room was unattended. 4. At approximately 9:58AM, one LI noted that the door to the second-floor laundry room near the elevators was unlocked and unattended. The room contained a one-gallon container of McKesson hydrogen peroxide. 5. At approximately 10:16AM, two LIs observed four cans of unopened beer sitting on top of an unattended medication cart on the second floor. Staff 3 was the registered medication aide that had possession of the keys to the medication cart.
Plan of Correction:	? Facility will ensure that all cleaning and other hazardous materials are stored in a locked area