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: Oct. 19, 2021 and Nov. 10, 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:

The licensing inspector (LI) for Runk & Pratt of Forest initiated a monitoring inspection on 10/19/2021 via telephone with the Administrator and requested documents via email for a self-report of a resident elopement. On 11/10/2021 the LI conducted an on-site inspection from 9:25 AM until 11:00AM. Sixty-six residents were in care at the time of the inspection. The LI reviewed documentation for one resident provided by the facility and observed multiple occupied residents' rooms during the on-site portion of the inspection on 11/10/2021. Findings were reviewed with facility staff during the inspection. An exit interview was conducted with the Administrator on 11/10/2021, 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. Violations were issued regarding the self-report and can be found on this violation notice. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions, contact your licensing inspector at (540) 589-5216.

Violations:

Standard #:	22VAC40-73-1150-B
Description:	Based on staff interview and observation, the facility failed to ensure that there were protective devices on the bedroom windows in residents? rooms and on windows in common areas accessible to residents to prevent the windows from being opened wide enough for a resident to crawl through. EVIDENCE: 1. Interview with Staff 4 revealed that when resident 1 crawled through his bedroom window to the outside of the facility on 10/15/2021, the safety device (a white, plastic rectangle piece screwed into the track of the window) that was on the window was not appropriately installed. The resident was able to open the window, tilt the window toward himself inside the bedroom, remove the window screen and climb out of the ground floor window onto the sidewalk outside of the facility. 2. During on-site inspection on 11/10/2021, at least the bedroom windows located in rooms A2, C5, C6, C7, D7 and E1 were able to be opened by the licensing inspector and staff 1. The windows had a white, plastic rectangle piece screwed into the track being used as safety devices; however, the inspector and staff 1 were able to open the windows high enough, slide the two buttons located on top of the windows to unlock the window from the tracks and then tilt the windows toward the inside of the residents? rooms. The windows in the above mentioned rooms opened normally, allowing enough space for a person to crawl through to the outside. 3. The window in room D7, closest to the end of the resident?s bed, did not contain a safety device thus allowing the window to open normally and completely. 4. The windows located along the hallways in the facility on the other side of the enclosed, outside courtyard contained white, plastic rectangle pieces screwed into the tracks being used as safety devices; however, multiple windows along the hallway were also able to be opened normally and completely by the licensing inspector and staff 1 during on-site inspection on 11/10/2021.
Plan of Correction:	Protective devices have been installed to all windows, all windows, the outside perimeter of building and the courtyard area.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure that the Individualized Service Plan (ISP) addressed all of the identified needs. EVIDENCE: 1. The ?Report of Resident Physical Examination? for resident 1, dated 08/06/2021, showed that the resident is ?non-ambulatory by reason of physical or mental impairment is not capable of self-preservation without the assistance of another person.? The ISP for resident 1, dated 08/06/2021, stated that the resident is ambulatory and ?physically and mentally capable of exiting building during emergency?. Interview with staff 1 revealed that the ISP is incorrect. 2. The ?Assessment of Serious Cognitive Impairment? for resident 1, dated 08/06/2021, showed that the resident ?can become agitated @ times, asks to go to the bank, flight risk?. These identified needs were not included on the ISP dated 08/06/2021 for resident 1.
Plan of Correction:	The day of inspection ISP corrected - ISP now reflects resident is non-ambulatory- ISP now reflects resident is a flight risk.
Standard #:	22VAC40-73-460-D
Description:	Based on resident record review and staff interview, the facility failed to ensure supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises. EVIDENCE: 1. The ?Report of Resident Physical Examination? for resident 1, dated 08/06/2021, showed that the recommendation for care for the resident was ?memory care, secure unit? and the resident is ?non-ambulatory by reason of physical or mental impairment is not capable of self-preservation without the assistance of another person.? 2. Resident 1 was admitted to the facility on 08/06/2021 which is a safe, secure environment. 3. The ?Assessment of Serious Cognitive Impairment? for resident 1, dated 08/06/2021, showed the resident?s behavior/psychomotor as ?can become agitated @ times, asks to go to the bank, flight risk?, has a serious cognitive impairment due to a primary diagnosis of dementia, and is unable to recognize danger or protect his own safety and welfare. The individualized service plan (ISP) for resident 1, dated 08/06/2021, does not address resident 1?s care needs of becoming agitated at times, asking to go to the bank and being a flight risk. 4. Incident report from staff 1 on 10/16/2021 stated that on 10/15/2021 ?staff realized that the resident?s (resident 1) window was open and the screen was missing. Staff told the administrator and then all staff stopped what they were doing and went on foot and in cars to find the resident.? Email sent to the licensing inspector (LI) by staff 1 on 10/19/2021 stated the following: ?(Staff 2) stated (resident 1) ate lunch and left dining room, resident stated he was going to take a nap, he locked his door and that is when aide (staff 2) came to in to my office (staff 1) to have me unlock door and check on him. He never announces he is taking a nap or locks his door.? Interview with staff 1 revealed that the resident eats lunch at 11:30 AM and was seen by staff in the dining room eating lunch at 11:30 AM on 10/15/2021. 5. An interview with staff 1 revealed that the resident left the facility through his ground floor window and facility camera footage, reviewed by staff 1, showed the resident on the sidewalk of the facility at 11:52 AM on 10/15/2021. Email sent to LI by staff 1 stated that the resident was found by staff 3 outside of Wells Fargo 17967 Forest Road Forest, VA 24551 and was brought back to the facility by staff 3 at 12:51 PM. Google maps shows that Wells Fargo bank is a 0.2 mile walk from the facility. 6. According to timeanddate.com, the temperature for 10/15/2021 from 11:54 AM to 12:54 PM was between 79 degrees Fahrenheit and 84 degrees Fahrenheit.
Plan of Correction:	The day of inspection ISP corrected now reflect resident is non-ambulatory and a flight risk.