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: May 14, 2024

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(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/14/2024 9:00am until 3:00pm 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: 50 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 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 #:	22VAC40-73-1040-A
Description:	Based on observations of the facility physical plant, the facility failed to ensure that a system of security monitoring was in place on all doors leading to the outside for residents with serious cognitive impairments. EVIDENCE: 1. At 10:30am on 05/14/2024 the licensing inspector in the presence of staff person 4 noted that the front doors to the facility did not have a system of security monitoring in place for residents with cognitive impairments. The facility houses a mixed population of residents such as resident 3, who is assessed with disorientation to all spheres some of the time on a uniform assessment instrument (UAI) dated 06/15/2023 and resident 4 who is assessed with disorientation to some spheres some of the time with person, place and situation as spheres affected on a UAI dated 04/01/2024.
Plan of Correction:	The main lobby doors leading to the outside will have a system of security monitoring installed. DOC ? June 14, 2024
Standard #:	22VAC40-73-210-B
Description:	Based on staff record review, the facility failed to ensure that direct care staff received at least 18 hours of training annually. EVIDENCE: 1. The record for staff person 2, hired on 01/16/2023 as a direct care aide, has documentation that this employee only received 13 hours of annual training from 01/16/2023 through 01/16/2024.
Plan of Correction:	Administrator/Designee will ensure that all direct care staff have 18 hours of training annually. DOC ? June 1, 2024
Standard #:	22VAC40-73-860-I
Description:	Based on observations of the facility physical plant, the facility failed to ensure that hazardous materials were stored in a locked area. EVIDENCE: 1. Two bottles of NUVEL Nail Polish Remover and a plastic basket with numerous bottles of finger nail polish were observed in an unlocked cabinet in the large activity room.
Plan of Correction:	Administrator/Designee with ensure that all chemical and hazardous materials are stored in a locked area. Routine rounds will be made to ensure that hazardous materials/chemicals are not available/within reach. DOC ? May 14, 2024