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: Yes

Areas Reviewed:

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

Comments:

Type of inspection: Complaint 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. A complaint was received by VDSS Division of Licensing regarding allegations in the area(s) of: Personnel and resident care and related services. 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: 4 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 investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident care and related services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-610-D
Complaint related:	Yes
Description:	Based on resident record review and observations of the facility mid-day meal, the facility failed to ensure that when a diet is prescribed for a resident by his physician or other prescriber, it is prepared and served according to the physician's or other prescriber's orders. EVIDENCE: 1. The record for resident 1 has documentation of a physician order dated 09/02/2021 for a no concentrated sweet (NCS), low cholesterol and low-fat diet. Interview with staff 3 in the presence of staff 1 and 2 explained that resident 1 was served a regular plate at the mid-day meal which included a regular slice of pie instead of a no concentrated sweets option. 2. The record for resident 3 has documentation of a physician order dated 03/13/2023 for a mechanical diet. The LI observed in the presence of staff 1 and 2 that resident 3 was served a regular plate at the mid-day meal which contained a regular lunch meat sandwich. 3. The record for resident 4 has documentation of a physician order dated 01/20/2023 for a chopped meat diet and nectar thick liquids. The LI observed in the presence of staff 1 and 2 that resident 4 was served a regular plate at the mid-day meal which contained a regular lunch meat sandwich and was also served a regular beverage that was not nectar thick in consistency.
Plan of Correction:	? Facility will ensure that staff are aware of all diet restrictions and all doctor orders are followed ? Any diet that is prescribed for a resident by their physician must be prepared and served according to the prescriber's orders. ? Any beverage that is served, complies in accordance with any specific diet order