VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Runk & Pratt of Forest
208 Gristmill Drive
Forest, VA 24551
(434) 385-0297

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Feb. 24, 2021

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 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.

Technical Assistance:

To ensure that the facility had a thorough understanding of standards, the licensing inspection had a discussion with the Administrator and the Assistant Administrator regarding standards 100 A, 260 and 700-1.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 02/23/2021 and concluded on 02/25/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 50. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, health care oversight, fire inspection, past three fire drills, most recent dietitian review, staff scheduled for the past two weeks and sworn disclosures and criminal record checks for all new hires since the facility's last mandated inspection submitted by the facility to ensure documentation was complete. The licensing inspector and the Administrator and Administrator Assistant had a discussion regarding standard 270. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1110-A
Description:	Based on resident record review, the facility failed to ensure that prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment there was written determination and justification for the decision from the licensee, administrator, or designee retained in the residents? files. EVIDENCE: 1. The records for residents 2 and 3 did not include a written determination and justification from the licensee, administrator, or designee prior to these residents being placed in the safe, secure environment.
Plan of Correction:	The Administrator/or designee will ensure that the appropriate of placement document will be reviewed and signed and placed in the resident record prior to move in.
Standard #:	22VAC40-73-270-1
Description:	Based on review of staff records, the facility failed to ensure training at least annually for staff in assisted living facilities that accept, or have in care, residents who are or who may be aggressive. EVIDENCE: 1. The record for staff 1, date of hire 10/15/2001, did not contain documentation that staff 1 had received annual aggressive behavior training during the training period 10/15/2019 through 10/14/2020.
Plan of Correction:	Staff 1 has received hands on aggressive resident training and methods of dealing with aggression.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure that the comprehensive individualized service plan (ISP) for a resident included a written description of what services will be provided to address identified needs. EVIDENCE: 1. The record for resident 2, admitted 01/28/2021, contained a physician?s order for ?Oxygen ? 2 L via nasal cannula prn sat <92%?. 2. The ISP for resident 2, with an identified need date of 02/19/2021, stated, ?Oxygen Therapy ? O2 will be kept at level as ordered by MD?. The ISP does not include a written description of the specific instructions prescribed by the physician for the oxygen therapy.
Plan of Correction:	Individual service plan ISP was updated to reflect the order and current needs of resident.
Standard #:	22VAC40-73-550-G
Description:	Based on resident record review, the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities were reviewed annually with each resident or his legal representative and written acknowledgment of the review was filed in the resident record. EVIDENCE: 1. The record for resident 1, admitted 02/26/2019, did not include documentation that the rights and responsibilities of residents in assisted living facilities were reviewed with resident 1 or the legal representative of resident 1 in 2020.
Plan of Correction:	Administrator or/and designated staff person will ensure that all annual review of resident rights and responsibilities is reviewed with each resident and/or their responsible party and it will be signed and dated.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review and staff interview, the facility failed to ensure that medications were administered in accordance with physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 2 contained a physician?s order, dated 02/20/2021, for ?Lasix 40 mg oral tablet SIG: 1.5 tab oral BID for 3 days?. 2. The February 2021 medication administration record (MAR) for resident 2 did not include documentation that this medication was administered to resident 2. 3. Interview with staff 4 confirmed that the medication had not been administered to resident 2. 4. The record for resident 3 contained a progress note by staff 5, dated 12/18/2020 at 12:47 PM, that ?Resident was seen in facility 12-18-20 by Dr. Betz she has new orders to increase Namenda to 10mg QHS daily POA is aware of the new order and the visit.? 5. ?Behavioral Health Documentation?, dated 01/29/2021, showed the following: ?Medications ? memantine (Namenda) 10 mg oral tablet, 10 mg = 1 tab, oral, bedtime?. This document contains an electronic signature from the physician on 01/29/2021 at 5:54PM. 6. The December 2020 and January and February 2021 medication administration records (MARs) for resident 3 contains no documentation that this medication had been administered to the resident.
Plan of Correction:	The DON or Designee will review all orders within 24 hrs. and to ensure all medications ordered are sent from the pharmacy. DON/Designee shall contact the pharmacy if pharmacy fails to send prescribed medications.