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: Sept. 21, 2022

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 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:

Type of inspection: Renewal Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 8:45AM through 3:00PM on 09/21/2022. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 55 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: one activity being held in the outdoor courtyard, noon-time meal, medication passes, and audit of all medication carts. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on facility document review, the facility failed to implement their medication management plan regarding methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The facility's medication management plan, revised in February 2021, states the following: "8. Methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes. RMA/LPN will count narcotics with on- coming/off-going shift and document in narcotic log record. 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. The document "Narcotic Count Key Transfer Sheet'' located in medication cart D for September 2022 was not completed for the following dates and shifts: On 09/17/2022, 11 PM - 7 AM Oncoming; On 09/18/2022, 11 PM - 7 AM Outgoing and 11 PM - 7 AM Oncoming; On 09/19/2022, 11 PM - 7 AM Outgoing; On 09/20/2022, 11 PM - 7 AM Oncoming; On 09/21/2022, 11 PM - 7 AM Outgoing and 7 AM - 3 PM Oncoming.
Plan of Correction:	RMAs/LPNs have been in serviced on signing of narcotic sheets before and after each shift. Designee will perform daily visual checks to ensure accuracy.
Standard #:	22VAC40-73-680-B
Description:	Based on observation during a tour of the facility's physical plant, the facility failed to ensure that medications remained in the pharmacy issued container until administered to residents. EVIDENCE: At approximately 9:04AM, the door to resident 1O's room was found to be open by one licensing inspector (LI) and the resident nor a staff member were found present in the room. The LI observed a small clear, plastic cup on the sink the resident's bathroom that contained a white substance and this was also observed by staff 3. Interview with staff 3 revealed that the resident has a prescription for Ammonium Lactate cream to be applied topically two times a day for dry skin and was most likely the cream found in the cup.
Plan of Correction:	Medications shall remain the pharmacy issued container, with the prescription label with direction label attached until administered to the resident. An in service will be conducted for RMAs/LPNs
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions. EVIDENCE: The record for resident 7 included a physician's order for Acetaminophen 325MG, dated 02/02/2022, take two tablets by mouth three times daily for pain. The September 2022 medication administration record (MAR) for the resident included documentation that this medication was not administered by staff 1 to the resident on 09/18/2022 at 3:00PM due to "outside of parameters: BP 120/88". The physician's order for the aforementioned medication does not include instructions that the medication can be held due to blood pressure parameters.
Plan of Correction:	All RMAs/LPNs have been retrained or, medications administration, five rights of medications administration and proper documentation.
Standard #:	22VAC40-73-870-A
Description:	Based on observation during a tour of the physical plant, the facility failed to ensure the interior of the building was maintained in good repair. EVIDENCE: During a tour of the facility's physical plant, one licensing inspector (LI) observed multiple black scuff marks on the walls in the "E" hallway and the dining room of the "E" section of the facility.
Plan of Correction:	The interior of the building of the facility will be maintained in good repair and kept clean. Walls were clean the day after inspection.