VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Runk and Pratt Willow Ridge
1213 Long Meadows Drive
Lynchburg, VA 24502
(434) 237-3009

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Aug. 29, 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 GROUNDS 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

Technical Assistance:

To ensure that the facility had a thorough understanding of the standards, the licensing inspector had a discussion with the facility?s administrator and the regional director regarding standard 22VAC40-73-1040A and 22VAC40-73-1040B.

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: 08/29/2024 9:00AM to 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: 96 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: activities, medication cart audits, medication administration 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 #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure the comprehensive individualized service plan (ISP) shall include a description of identified needs. EVIDENCE: 1. The ISP for resident 3, dated 07/12/2024 and completed by staff person 2, indicates that the resident is to have safety checks every two hours due to the resident?s inability to use call bell due to cognitive or physical impairment and direct care staff will monitor resident every two hours. 2. Interview with staff person 3 revealed that staff person 2 indicated to her during the on-site inspection that the resident does know how to use the call bell and therefore does not require monitoring every two hours and should not be an identified need on the resident?s ISP.
Plan of Correction:	Administrator/Designee will ensure accuracy of care plans and UAI?s based on resident needs.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The August 2024 medication administration record (MAR) for resident 1 indicates that the resident was not administered the following medications due to the medication not being available in the facility: daily-vite 400MCG at 8:00AM on 08/13/2024 and 08/14/2024 and escitalopram 2.5MG at 8:00AM on 08/13/2024 and 08/14/2024. 2. The August 2024 MAR for resident 2 indicates that the resident was not administered the following medications due to the medication not being available in the facility: carvedilol 6.25MG at 8:00PM on 08/13/2024 and melatonin 5MG and 3MG at 8:00PM on 08/13/2024.
Plan of Correction:	Medications will be administered according to physician orders. Administrator/Designee will ensure staff are following orders accurately.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, the facility failed to ensure the medication administration record (MAR) shall include the date and time given and initials of direct care staff administering medication. EVIDENCE: 1. The August 2024 MAR for resident 1 did not include the initials of the direct care staff who administered the following medications to the resident: divalproex 250MG at 12:00PM on 08/26/2024 and 08/28/2024; quetiapine 100MG at 8:00PM on 08/23/2024 and 08/24/2024; and lorazepam 1MG at 2:00PM on 08/26/2024 and 08/28/2024 and at 8:00PM on 08/12/2024 and 08/24/202. 2. The August 2024 MAR for resident 2 did not include the initials of the direct care staff who administered the following medication to the resident: buspirone 10MG at 12:00PM on 08/28/2024.
Plan of Correction:	Facility will ensure that all medication administration records are accurate and reflect current diagnosis, condition, or specific indications for administering the drug or supplement.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review and staff interview, the facility failed to ensure that criminal history record reports shall be obtained on or prior to the 30th date of employment for each employee. EVIDENCE: The criminal history record report for staff person 1, date of hire 07/15/2024, had not been obtained by the facility as of day of on-site inspection.
Plan of Correction:	Administrator/Designee to ensure the requirements specified in the Regulation for Background Checks are complete in a timely manner and placed in employee file.