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 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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. A self-reported incident was received by VDSS Division of Licensing regarding allegations in the area(s) of: 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: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 #:	22VAC40-73-1040-A
Description:	Based on observations made of the facility physical plant, the facility failed to ensure that doors leading to the outside have a system of security monitoring of residents with serious cognitive impairments. EVIDENCE: 1. The sliding glass doors in the facility fitness room and the Pratt Chapel that lead to the outside did not have a system of security monitoring of residents with serious cognitive impairments on the day of inspection. 2. The alarms on the doors that lead to the outside by room 134, the AL dining room door and the door to the end of the hall on the right on AL1 were inoperable/turned off on the day of inspection.
Plan of Correction:	Facility will ensure and confirm that all doors leading to the outside are alarmed to alert staff if any resident with a serious cognitive impairment of dementia has opened the door.
Standard #:	22VAC40-73-1040-B
Description:	Based on observations made of the facility physical plant, the facility failed to ensure that protective devices were on windows in common areas accessible to residents with serious cognitive impairments to prevent the windows from being opened wide enough for a resident to crawl through. EVIDENCE: 1. Two windows located in the facility fitness room and 4 windows located in the Pratt chapel were noted to lack protective devices to prevent the windows from being opened wide enough for a resident to crawl through on the day of inspection.
Plan of Correction:	Facility will ensure that protective devices are on windows and doors in common areas so that residents can not crawl through. In compliance with fire code- doors and windows have been permanently sealed .
Standard #:	22VAC40-73-460-D
Description:	Based on resident record review and staff interview, the facility failed to provide supervision of resident schedules, care, and activities, including attention to the specialized need of wandering from the premises. EVIDENCE: 1. The record for resident 1, admitted to the facility on 10/25/2021 has documentation on a history and physical dated 09/16/2021 that the resident has a diagnosis of dementia. A history and physical report dated 07/05/2022 from the local hospital has documentation that resident 1 has a history of advanced Alzheimer?s type dementia and that the resident is a poor historian due to his severe dementia. A physician order sheet signed 10/31/2022 has documentation that the resident has a diagnosis of dementia with behavior and that the resident is followed by neurology for Alzheimer?s. 2. The uniform assessment instrument (UAI) dated 10/25/2022 in the record for resident 1 has documentation that the resident is disoriented to some spheres some of the time with time, place and situation being the spheres affected. The individualized service plan (ISP) dated 10/25/2022 in the record for resident 1 has documentation that the resident is disoriented to some spheres some of the time with time, place and situation being the spheres affected. The ISP has documentation that staff may orient upon discretion, support resident during episodes of disorientation and reassure safety at the facility. 3. Progress notes in the record for resident 1 has documentation on 02/24/2023 that the resident was seen by their doctor for increased behaviors. On 02/25/2023 at late entry was noted in progress notes for resident 1 at 11:28am for 02/23/2023 at 5pm which documented that resident 1 was displaying behaviors while on the facility bus and was returned to the facility. Documentation also notes that resident 1 was observed trying to exit the locked facility but was unsuccessful. Documentation in progress notes on 02/25/2023 at 11:37am notes that resident 1 was observed during the third shift to come out of his room and going in a different direction than normal and that resident 1 was observed trying to head out of the front door of the facility and was redirected by staff. 4. Progress notes dated 02/25/2023 at 11:45 am has documentation that ?kitchen aide observed resident being brought in by a bystander. Bystander stated resident was on the main road on Candlers Mtn walking in the direction towards Sunnymeade Rd. Bystander stated he observed the resident looking lost and confused. Bystander was jogging and noticed resident- and brought him back to the facility.? 5. Staff 1 expressed in an interview conducted on 03/17/2023 that they were uncertain what time resident 1 left the facility on 02/25/2023 but that resident 1 was observed in the facility dining room during breakfast on the morning of 02/25/2023 and was also observed sometime after breakfast sitting in the lobby area of the facility. Staff 1 expressed that resident 1 was returned to the facility at 11:00am on 02/25/2023.
Plan of Correction:	? Any resident that exhibits or displays disorientation in relation to a medical diagnosis of dementia will be reviewed for proper placement in an assisted living facility. ? Staff will recognize any patterns that support any signs of dis-orientation.