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. 17, 2023

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: 11/17/2023 9:00am until 1:30pm 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: 106 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 13 Number of staff records reviewed: 9 Number of interviews conducted with residents: 3 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 #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure the comprehensive Individualized Service Plan (ISP) shall be completed within 30 days after admission and shall include a description of identified needs and date identified based upon the Uniform Assessment Instrument (UAI). EVIDENCE: 1. During an on-site inspection on 11/17/2023, the UAI in the record dated 10/4/2023 for resident 4 indicated that the resident is appropriate in behavior pattern. The comprehensive ISP in the record dated 10/4/2023 for resident 4 indicated that resident is wandering/passive, greater than weekly in behavior patterns. During an interview with two licensing inspectors (LIs), staff 5 revealed that the UAI for the resident was accurate.
Plan of Correction:	? Facility will ensure that the comprehensive ISP will be completed within 30 days after admission and shall include a description of identified needs and date identified upon the UIA
Standard #:	22VAC40-73-640-A
Description:	Based on resident record review and staff interview, the facility failed to ensure to implement its written medication management plan regarding identification of the medication aide or the person licensed to administer drugs responsible for routinely communicating issues or observations related to medication administration to the prescribing physician or other prescriber. EVIDENCE: 1. The facility?s medication management plan states the following in regard to identification of the medication aide or the person licensed to administer drugs responsible for routinely communicating issues or observations related to medication administration to the prescribing physician or other prescriber: ?all staff is responsible for communication daily, per shift, to the Lead RMA, Administrator/DON any change in condition, problems, concerns, falls or other issues of a resident that could have a negative effect on their medical status. The Lead RMA is responsible for communicating problems, concerns or changes in condition with the assigned physician by either fax or phone. A copy of all communications or orders per the doctor can be found in the resident?s chart.? and ?All falls, concerns, pain or any other issues are communicated to doctor or Nurse Practitioner via phone and/or fax and can be found in the resident?s chart.? 2. The record for resident 2 contains a physician?s order, dated 10/18/2023, for the facility to obtain daily morning weights for the resident and to call cardiology for any weight loss or gain of three pounds overnight or five pounds in a week or increase in heart failure symptoms. The October 2023 medication administration record (MAR) for resident 2 contains documentation from that 10/18/2023 through 10/31/2023 the resident refused staff to obtain her morning weight 11 times and the November 2023 MAR for resident 2 contains documentation from 11/01/2023 through 11/17/2023 the resident refused staff to obtain her morning weight 10 times. 3. The record for resident 2 contains a physician?s order, dated 10/16/2023, for Humalog sliding scale insulin before meals and at bedtime daily and Lidocaine 5% patch daily in which the resident?s MAR indicates the patch will be applied to the resident?s back every morning and removed at bedtime for pain. The October and November 2023 MARs for resident 2 contains documentation that on numerous days during October and November 2023 the resident refused blood sugar checks, Humalog insulin and Lidocaine patches. During on-site inspection on 11/17/2023, the record for resident 2 did not contain documentation that the resident?s aforementioned refusals had been communicated to the resident?s physician(s) and interview with staff person 5 confirmed that this was accurate.
Plan of Correction:	? Facility will ensure that its written medication management plan regarding routinely communicating issues or observations related to med administration to the prescribing physician.
Standard #:	22VAC40-73-860-I
Description:	Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area. EVIDENCE: 1. At 9:32am on the day of inspection 2 LI?s observed the that the door to the kitchenette on the first floor across from room 132 was unlocked. A can of Fresh-n-Clean Air Freshener and a container of Sani-Cloth Plus Germicidal Cleaner was observed in an unlocked cabinet under the sink in the kitchenette.
Plan of Correction:	? Facility will ensure that cleaning supplies are stored in a locked area
Standard #:	22VAC40-90-30-B
Description:	Based on staff record review, the facility failed to ensure that a sworn statement or affirmation shall be completed for all applicants for employment. EVIDENCE: 1. The record for staff 7 noted that their date of hire was 8/23/2023 and their first day of work was 8/24/2023; however, the sworn statement or affirmation for adult facility employees was not signed by staff 7 until 8/25/2023. 2. The record for staff 8 noted that their date of hire was 8/9/2023 and their first day of work was 8/10/2023; however, the sworn statement or affirmation for adult facility employees did not have a date when the signature was provided. 3. The record for staff 9 noted that their date of hire was 3/28/2023 and their first day of work was 4/7/2023; however, the sworn statement or affirmation for adult facility employees was not signed by staff 9 until 5/3/2023.
Plan of Correction:	? Facility will ensure that a sworn statement or affirmation shall be completed for all applicants for employment