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: Feb. 29, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/29/2024 8:30AM until 10:15AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 02/21/2024 regarding allegations in the area of: resident care and related services An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations, area(s) of non-compliance with standard(s) or law were: resident care and related services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-680-M
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility. EVIDENCE: 1. The record for resident 1 contained a physician?s order, dated 01/08/2024, for morphine 0.25ML (5MG) as needed every 3 hours for shortness of breath/pain. A bottle of morphine containing 15ML of morphine was delivered to the facility on 01/08/2024 for resident 1. 2. The record for resident 1 contained a physician?s order, dated 02/17/2024, to discontinue the previous morphine order and to start morphine 1ML (20MG) as needed every 15 minutes for end-of-life care and morphine 0.75ML as needed every 3 hours for end-of-life care. 3. The controlled drug record for resident 1?s prescribed morphine indicates that the resident received morphine from their prescribed bottle of morphine that was delivered to the facility on 01/08/2024 from 02/15/2024 at 11:40AM through 02/17/2024 at 4:00PM. 4. When the last dose was used from resident 1?s prescribed bottle of morphine, staff person 1 then used resident 2?s prescribed bottle of morphine and administered 27 doses of this morphine to resident 1 on 02/17/2024 because there was no additional morphine available in the facility for resident 1. 5. Phone interview with staff person 1 on 03/01/2024 confirmed that she did administer morphine that was prescribed for resident 2 to resident 1 because there was no additional morphine in the facility for resident 1 when she administered the last dose from resident 1?s bottle.
Plan of Correction:	3-4-2024 - Inservice conducted with all medication aides - in the in-service medication aides were instructed to abstain from using another resident's medication when advised from a hospice agency. Medication aides also instructed to ensure a refill is prescribed by hospice and delivered to the community for the prescribed resident before administering medication.