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 8, 2023

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 inspector was on-site at the facility for each day of the inspection: 06/08/2023 8am until 2pm 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: 56 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:2 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The record for resident 2 has a physician order dated 05/22/2023 to elevate legs when at rest every shift and to discontinue lactose intolerant on resident 2?s diet. The ISP dated 05/17/2023 in the record for resident 2 does not address the identified need for the residents legs to be elevated at rest every shift and still contains documentation that the resident is lactose intolerant.
Plan of Correction:	On day of inspection, Resident?s ISP was updated to reflect elevation of legs and discontinue lactose intolerance from the ISP. Random audits will be performed to ensure resident needs are updated and identified on the resident ISP.
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 physician instructions. EVIDENCE: 1. The record for resident 7 has a physician order dated 05/10/2023 for Bleph 10, 2 drops in left eye four times a day for 7 days for conjunctivitis. The May 2023 MAR for resident 7 does not have documentation of this physician order being transcribed to the MAR or documentation of staff initials for the administration of the medication. Interview with staff 5 verified that this was correct.
Plan of Correction:	Medications will be administered according to physician orders or other prescribers? instructions. Administrator/Designee will ensure physician orders are faxed to the pharmacy and transcribed to the electronic MAR for administration.
Standard #:	22VAC40-73-680-I
Description:	Based on a review of resident records and medication administration records (MARs), the facility failed to ensure that all required information was included on resident MARs. EVIDENCE: 1. The record for resident 5 has a physician order dated 02/08/2023 for ?Oxygen @ 2L PRN for comfort if short of breath (via nasal Cannula)?. The May and June 2023 MARs for resident 5 do not have documentation of the order for oxygen.
Plan of Correction:	Administrator/Designee will ensure that all prescribed medications/orders will be placed and documented on the resident MAR. The oxygen order was placed on the resident MAR on 6/9/2023.
Standard #:	22VAC40-73-870-A
Description:	Based on observations of the facility physical plant, the facility failed to maintain the interior of the building in good repair. EVIDENCE: 1. The Activity/Dining room was noted to have several stains on the ceiling. 2. The Activity room near the Therapy area was noted to have ceiling stains to the right near the fire sprinkler.
Plan of Correction:	The facility interior will remain in good repair. Maintenance will repair the activity/dining room ceiling stains.