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: Oct. 3, 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: 10/03/2023 9:00am until 1:30pm 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 on regarding allegations in the area(s) of: Staffing, Resident care and related services, Building and Grounds. Number of residents present at the facility at the beginning of the inspection: 108 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: 3 Number of interviews conducted with staff: 5 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 complaints 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 #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on observations of the facility medication carts, the facility failed to implement their medication management plan (MMP) in regard to the monitoring of controlled substance to ensure accurate counts. EVIDENCE: 1. The facility MMP dated 2/2021 has documentation that ?A narcotic log is completed by off-going and on-coming RMAs/LPN and a signature is required by both RMAs/LPN per shift?. 2. On October 3, 2023, one Licensing Inspector (LI) and staff 1 observed that the October 2023 ?Narc Count? signature form for the 1st AL Hall did not contain signatures on the following dates and shifts: a. October 1, 2023 by the 11 ? 7 outgoing Registered Medication Aid (RMA) and 11 ? 7 oncoming RMA. b. On October 2, 2023 by the 11 ? 7 outgoing RMA, 7 -3 oncoming RMA, 7-3 outgoing RMA, 3 ? 11 oncoming RMA, 3 ? 11 outgoing RMA, and 11 ? 7 oncoming RMA. c. On October 3, 2023 by the 11- 7 outgoing RMA and 7 ? 3 oncoming RMA.
Plan of Correction:	? Facility will ensure that narc log is completed by off-going / on ?coming RMA- Facility will ensure a signature is required to complete task.
Standard #:	22VAC40-73-680-C
Complaint related:	Yes
Description:	Based on observation of the morning medication pass, staff interview and resident record review, the facility failed to ensure that medications shall be administered not earlier than one hour before and not later than one hour after the facility?s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. EVIDENCE: 1. The record for resident 1 contains physician?s orders, dated 08/07/2023, that the resident is to receive the following medications at 8:00AM; Acetaminophen 325MG, Azelastine nasal spray, Breztri inhaler, Buproprion HCL 75MG, Diclofenac sodium gel, Dorzolamide-timolol eye drops, Lidocaine pain patch, Guaifenesin er 600MG, Refresh classic eye drops, Senna 8.6MG, Topiramate 50MG, Vitamin D3 2,000 unit and Xarelto 20MG. During on-site inspection on 10/03/2023, one licensing inspector (LI) observed that staff 3 administered the aforementioned medications to resident 1 at 9:15AM. 2. The record for resident 4 contains a physician?s order, dated 08/15/2023, that the resident is to receive the following medications at 8:00AM; Amlodipine besylate 10MG, Aspirin 81MG, Caltrate plus chew, Esomeprazole 40MG, Azo cranberry gummy, Ramipril 5MG, MPAP ER 650MG, Probiotic, Vitamin D3, Docustate sodium 100MG and Fluticasone nasal spray. During on-site inspection on 10/03/2023, one LI observed that staff 3 administered the aforementioned medications to resident 4 at 9:25AM. 3. The record for resident 2 contains a physician?s order, dated 09/12/2023, that the resident is to receive the following medications at 8:00AM; Furosemide 20MG, Losartan Potassium 25MG and Memantine HCL10MG and the record for resident 3 contains a physician?s order, dated 09/04/2023, that the resident is to receive the following medications at 8:00AM; Atorvastatin 40MG, Diltiazem 24hour ER 180MG, Doxycycline HYC 100MG, Irbesartan 150MG, Metoprolol tart 25MG, Multivitamin with minerals and Vitamin D3 1,000 unit. During on-site inspection on 10/03/2023 at approximately 9:30AM, interview with staff 3 revealed that the aforementioned 8:00AM medications had not been administered to residents 2 and 3. 4. The record for resident 5 has physician order?s dated 09/07/2023 that the resident is to receive tha following medications at 7am; Atenolol 50mg tablet, Furosemide 20mg tablet, Levothyroxine 50mcg tablet, Metformin 50mcg tablet, Omega 1200mg capsule, Vitamin D3 5000 Unit capsule, and Xarelto 20mg tablet. During on-site inspection on 10/03/2023, one LI observed that staff 1 administered the aforementioned medications to resident 5 at 9:22AM.
Plan of Correction:	? Facility will ensure that medications will be administered one hour before / after the standard dosing schedule .
Standard #:	22VAC40-73-680-I
Complaint related:	Yes
Description:	Based on observation of the morning medication pass, staff interview, and resident record review, the facility failed to ensure that the medication administration record (MAR) shall include any medication errors or omissions. EVIDENCE: 1. The record for resident 1 contains a physician?s order, dated 08/07/2023, for the resident to receive an Ensure liquid drink with meals for supplement daily at 8:00AM. 2. During the morning medication pass observation on 10/03/2023, staff 3 informed the licensing inspector (LI) that the resident did not have anymore Ensure and that she would have to place an order on this date for more; however, staff 3 documented on the resident?s October 2023 MAR that the resident received an Ensure at 8:00AM on 10/03/2023.
Plan of Correction:	? Facility will ensure that the MAR shall include any med errors or omissions.