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: March 2, 2023

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

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/02/2023 10:00AM until 11:30AM in conjunction with local adult protective services. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 02/14/2023 regarding allegations in the areas of: resident care and related services and additional requirements for facilities that care for adults with serious cognitive impairments 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 #:	22VAC40-73-660-A-2
Description:	Based on document review and staff interview, the facility failed to ensure schedule II drugs and any other drugs subject to abuse were kept in a separate locked storage compartment. EVIDENCE: 1. On 02/14/2023, the licensing inspector (LI) was notified by staff 1 via phone call and email that resident 1 had gone into the nurses? station at 9:01PM on 02/13/2023 and was seen on camera using the passcode to gain access to the locked nurses? station and then was seen leaving the nurses? station with a bottle of morphine that was in the pharmacy return box. 2. Interview with staff 1 confirmed that the bottle of morphine that was in the locked nurses? station was not in a separate locked storage container therefore it was not double-locked.
Plan of Correction:	On 2/14/23 maintenance installed a Lockly Secure Lock - a biometric locking system individualized system customized for each staff member to the nursing station door. Pharmacy return boxes now have combination locks on their boxes to ensure medications are double-locked at all times.