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: Aug. 27, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

A focused, non-mandated monitoring inspection was initiated on 08/27/2021 and concluded on 08/27/2021 to determine correction and compliance with B2 violations cited during a previous focused, non-mandated monitoring inspection in the areas of resident care and additional requirements for facilities that care for adults with serious cognitive impairments. The Administrator was contacted by telephone to conduct the inspection. The licensing inspector emailed the Administrator a list of documentation required to complete the inspection. The licensing inspector reviewed one resident record (physician's orders and medication administration record) and the facility's night staff schedule for the past five (5) days. Previous violations were reviewed. One violation is being cited as a repeat. Any additional violations identified during the course of the inspection can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-1130-C
Description:	Based on document review and staff interview, the facility failed to ensure during night hours that when more than 40 residents are present, at least four direct care staff members plus at least one more direct care staff member for every additional 10 residents, or portion thereof, shall be awake and on duty at all times in each special care unit and shall be responsible for the care and supervision of the residents. EVIDENCE: 1. Document provided by staff 1, "Census Report by Head Count", for August 2021 revealed that the facility's census for the time period of 08/22-23/2021 was 60 and for the time period of 08/24/2021 through 08/26/2021 was 61 each day. The night shift hours for the facility are 11PM through 7AM. Based on the census, there should have been 6 direct care staff on duty at all times during the night hours of 08/22/2021 and 7 direct care staff on duty at all times during the night hours on 08/24/2021 through 08/26/2021. The staff schedule provided by staff 1 showed that only 4 direct care staff worked on the 11PM through 7AM shift on the nights of 08/22/2021 and 08/25/2021 and only 6 direct care staff worked on the nights of 08/24/2021 and 08/26/2021. Interview with staff 1 confirmed that this was accurate.
Plan of Correction:	Administrator or designee will ensure staffing is appropriate for number of residents residing in facility.
Standard #:	22VAC40-73-650-A
Description:	Based on resident record review, the facility failed to ensure that medications were not discontinued without a valid order from a physician or other prescriber. EVIDENCE: 1. The record for resident 1 contained a physician's order, dated 06/23/2021, for "Quetiapine Fumarate 25 MG TAB (Seroquel 25 MG Tablet) - Take 1 Tablet By Mouth Daily As Needed for Mood Disorder". 2. The August 2021 medication administration record (MAR) for resident 1 did not contain information that this medication was available to the resident as needed and the record for resident 1 did not contain a physician's order to discontinue this medication. Interview with staff 1 confirmed this information was accurate.
Plan of Correction:	1.) Pharmacy was contacted and made aware the "as needed dose" was discontinued by pharmacy and never re-entered to MAR. 2.) Day of inspection order corrected and returned to MAR 3.) DON/Designee will audit new orders/MAR within same day as new physician orders written to ensure placement on MAR