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: Nov. 7, 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

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: 11/07/2024 7:30AM to 2:45PM 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: 34 assisted living level of care, 69 independent living 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: 3 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 6 Observations by licensing inspector: morning medication administration, noon-time meal, activity, medication cart audits 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 1, dated 06/28/2024; the ISP for resident 2, dated 06/28/2024 and the ISP for resident 4, dated 09/13/2024 indicate that residents 1, 2 and 4 are to have safety checks every two hours due to their 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 4 revealed that staff person 5 indicated to her during the on-site inspection that residents 1, 2 and 4 do know how to use the call bell and therefore do not require monitoring every two hours and this should not be an identified need on the ISPs for residents 1, 2 and 4.
Plan of Correction:	Administrator/Designee will ensure accuracy of care plans and UAI?s based on resident needs.
Standard #:	22VAC40-73-640-A
Description:	Based on medication cart audit and staff interview, the facility failed to implement its medication management plan in regard to methods to prevent the use of outdated medications and methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The facility?s medication management plan (MMP) states medications that have been discontinued or found to be contaminated, damaged, and/or outdated should be disposed of properly and medication carts will be audited randomly by Administrator or Designee on alternating shifts. Interview with staff person 6 revealed that the plan should include that insulin pens, once opened, should contain the date the pen was opened due to insulin pens having an expiration date once opened. The A hall and L side of B hall medication cart contained a lantus insulin pen in the top drawer that had been opened but did not contain a date of when the insulin pen had been opened and did not contain the name of the resident the lantus insulin pen belonged to. Interview with staff person 1 revealed the lantus insulin pen belongs to resident 8. 2. The facility?s MMP states a narcotic log is completed by off-going and on-coming RMAs/LPN and a signature is required by both RMAs/LPN per shift to ensure an accurate count of all controlled substances whenever assigned medication administration staff changes. The B hall medication cart?s narcotic log for November 2024 does not contain the signature of the on-coming registered medication aide (RMA) (11PM-7AM) on 11/05/2024 or the off-going RMA (11PM-7PM) on 11/06/2024. Interview with staff person 1 revealed to the licensing inspector (LI) that they counted with the off-going RMA the morning of 11/07/2024; however, staff person 1 did not sign the narcotic log located in the B hall medication cart after counting the narcotics with the off-going RMA.
Plan of Correction:	Administrator/Designee will ensure the registered medication aides follow the approved medication management plan to address procedures for administering medication.
Standard #:	22VAC40-73-660-A
Description:	Based on observation during morning medication administration, the facility failed to ensure a medicine cabinet, container, or compartment that is used for storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility shall be locked and the individual responsible for medication administration shall keep the keys to the storage area on their person. EVIDENCE: At approximately 7:35AM, the licensing inspector (LI) observed staff person 1 going into a resident?s room to administer medications and left the medication cart unlocked, left the keys to the medication cart in the lock, and left medications sitting on top of the medication cart unattended.
Plan of Correction:	Administrator/Designee will ensure the medication cart is locked at all times.
Standard #:	22VAC40-73-660-B
Description:	Based on observation during a tour of the facility, resident interview, resident record review and staff interview, the facility failed to ensure a resident may be permitted to keep his own medication in an out-of-sight place in his room if the UAI (uniform assessment instrument) has indicated that the resident is capable of self-administering medication. EVIDENCE: 1. The UAI for resident 7, reassessment date 11/04/2024, indicates that the resident requires his medications to be administered/monitored by lay person ? registered medication aide and/or nurse. 2. The licensing inspector (LI) observed a bottle of equate brand acetaminophen 500MG tablets in the resident?s room beside the recliner the resident was sitting in. During an interview with resident 7, the resident informed the LI that he takes two tablets of the acetaminophen every 6 hours. 3. The record for resident 7 does not contain an order that the resident can have and self-administer the medication. Interview with staff person 5 confirmed this is accurate.
Plan of Correction:	Administrator/Designee will ensure residents permitted to keep his/her own medication in an out of sight place in his/her room.
Standard #:	22VAC40-73-680-B
Description:	Based on observation during morning medication administration and staff interview, the facility failed to ensure medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. EVIDENCE: At approximately 7:37AM, the licensing inspector (LI) noted there were four small, clear, plastic cups sitting on top of the medication cart that had names written on them with a black marker. The LI asked staff person 1 about the cups that contained pills in them and staff person 1 stated they were for residents 1 and 5 and that she had pre-poured their medications to give to administer to them.
Plan of Correction:	Administrator/Designee will ensure the medication(s) remain in the pharmacy issued container with the prescription label or direction label attached, until administered to the resident.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review and staff interview, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 7 contains an order, dated 11/04/2024, for calmoseptine 0.44% - 20.6% topical ointment two times daily apply to buttocks; however, the November 2024 medication administration record (MAR) for resident 7 contains two different entries for the ointment; one entry is for two times daily at 8:00AM and 8:00PM and one entry is for three times daily at 8:00AM, 2:00PM and 8:00PM. 2. Interview with staff person 5 revealed to the licensing inspector (LI) that staff have been applying it three times daily since the 11/04/2024 order was written instead of two times daily.
Plan of Correction:	Administrator/Designee will ensure medications are administered in accordance with the physician and/or other prescribers? instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Standard #:	22VAC40-73-680-M
Description:	Based on medication cart audit, resident record review and staff interview, the facility failed to ensure medications ordered for PRN (as needed) administration shall be available, properly labeled for the specific residents, and properly stored at the facility. EVIDENCE: The record for resident 6 contains an order, dated 11/05/2024, for loperamide 1MG/7.5ML take 15MLs (=2MG) by mouth four times a day as needed for loose stool. Interview with staff person 1 revealed that this medication is not available at the facility for the resident.
Plan of Correction:	Administrator/Designee will ensure that PRN medications are available, and properly labeled for specific resident information and properly stored.