VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Runk & Pratt Residential Adult Care of Lynchburg
20212 Leesville Road
Lynchburg, VA 24502
(434) 237-7809

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: June 21, 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.

Comments:

A renewal inspection was initiated on 6/21/2021 and concluded on 6/25/2021. The Administrator was contacted by telephone to initiate the inspection. The (person in Administrator reported that the current census was 45. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 3 resident records, 3 staff records, Health care and Dietician oversight, Fire and Health Inspections and fire drill logs submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 6/25/2021. An exit interview was conducted with Administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. 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 #:	22VAC40-73-260-C
Description:	Based on observations made during a tour of the facility physical plant conducted on 6/25/2021, the facility failed to ensure that a listing of all staff current in first aid and/or CPR was post in the facility. EVIDENCE: 1. A listing of staff who are current in first aid/CPR was not posted in the facility at the time of this inspection.
Plan of Correction:	A list of staff who are current in First Aid/CPR was posted at time on inspection.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to esure that all identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The ISP dated 6/7/21 in the record for resident 2 has documentation of home health for an identified need but does not specify what services home health is providing for the residents wound care needs. 2. The ISP dated 5/12/21 in the record for resident 3 has documentation of home health for an identified need but does not specify what services home health is providing for the residents wound care needs. Also the record for resident 3 has a physician order to crush medications if applicable and administer in pudding, applesauce or yogurt. The ISP does not address this identified need.
Plan of Correction:	Resident 2 ISP has been updated to reflect specific services that home health is providing for resident wound care needs. Resident 3 ISP has been updated to reflect specific services I home health needs for wound care. Resident 3 ISP has been updated to reflect crush meds to be administered in pudding, applesauce or yogurt if applicable.
Standard #:	22VAC40-73-680-D
Description:	Based on a review of resident records and medication administration records (MARs), the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions. EVIDENCE: 1. The record for resident 3 has a physician order dated 6/11/2021 for Ibuprofen 200mg, 1 tablet my mouth twice a day for 5 days. The June 2021 MAR for resident 3 does not have documentation that this physicians order was ever transcribed to the MARs and there are no staff initials to indicate that the medication was administered.
Plan of Correction:	Nurse/RMA will administer meds according to physicians or other prescriber's instructions. Unit Manager or designee will ensure orders are reflected on medication record as prescribed by physician. Nurse/RMA will follow prescribed orders as indicated for medication administration. Nurse/RMA staff will be in serviced on following physician prescribed orders and medication administration record.
Standard #:	22VAC40-73-680-M
Description:	Based on observations of the facility medication carts conducted on 6/25/2021, the facility failed to ensure that all PRN medications ordered for a resident was available, properly labeled for the specific resident, and properly stored at the facility. EVIDENCE: 1. The record for resident 2 has a physician order for Pepto-Bismol Suspension, 30mls by mouth 4 times a day as needed for indigestion. This medication was not available on the cart on the day of inspection.
Plan of Correction:	Resident 2 PRN Pepto-Bismol Suspension was delivered and placed on med cart for administration as needed. United Manager or designee will ensure PRN meds are available at all times for residents as prescribed by physician thru scheduled cart audits.
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during an on-site inspection conducted on 6/25/2021, the facility failed to maintain the exterior of the building in good repair. EVIDENCE: 1. A white column to the left of the front doors was noted to be broken completely from the bottom pedestal.
Plan of Correction:	Maintenance will repair bottom pedestal of white column to maintain the exterior of the building in good repair.