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: Dec. 17, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL

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: 12/17/2024 8:40AM to 10:31AM 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: 35 assisted living level of care, 69 independent living Number of resident records reviewed: 0 Number of staff records reviewed: 12 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 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 #:	22VAC40-73-120-A
Description:	Based on staff record review and staff interview, the facility failed to ensure the orientation and training required in 22VAC40-73-120-B and 22VAC40-73-120-C occurred within the first seven working days of employment. EVIDENCE: 1. On 12/17/2024, the day of on-site inspection, the facility daily assignment logs have documentation that staff person 6, date of hire 09/11/2024 and start date 09/23/2024, and staff person 9, date of hire 11/04/2024 and start date 11/07/2024, worked more than seven days between 11/03/2024 to 12/16/2024. 2. The records for staff persons 6 and 9 did not contain documentation that these staff persons completed the required orientation and training within the first seven working days of employment. In an interview with 2 licensing inspectors (LIs) and staff person 7 on the day of on-site inspection, staff person 7 acknowledged that there was no documentation of any orientation in the records for staff persons 6 and 9 and was unable to confirm if an orientation and training had been completed for these two staff persons.
Plan of Correction:	Administrator or Designee will ensure that staff orientation and initial training has been completed within seven working days of employment. Additionally, documentation of this training will be kept in the employee?s file.
Standard #:	22VAC40-73-150-C
Description:	Based on review of staff records, facility documentation and interviews with staff, the facility administrator failed to be responsible for the general administration and management of the facility and oversee day to day operations of the facility regarding training and supervision of staff. EVIDENCE: 1. During on-site inspection conducted on 12/17/2024, staff persons 3, 4, and 5 hired during staff person 1?s time as the facility administrator were noted to be on the facility daily assignment sheets from 11/03/2024 through 12/15/2024 working independently as direct care staff. In an interview conducted on-site on 12/17/2024 with 2 licensing inspectors (LI?s) and staff persons 1 and 2, staff persons 1 and 2 confirmed that the direct care training that staff persons 3, 4 and 5 received did not follow the department approved curriculum as it was not provided by a registered nurse or licensed practical nurse, which does not meet the requirements of 22VAC40-73-200-C.7. The records for staff persons 8, 9 and 10 were noted to be on the facility daily assignment sheets from 11/03/2024 to 12/15/2024 working independently as direct care staff but the records for these staff do not have documentation of a certificate for completion of a direct care staff training. Interview with staff persons 1 and 2 confirmed this is accurate. 2. During on-site inspections conducted on 12/17/2024, 6 employees hired between 07/03/2024 to 11/22/2024 who have not yet met required training as outlined in standard 22VAC40-73-200-C-1 through 7 were noted to be on the facility daily assignment sheets working independently as direct care staff. Staff person 1 confirmed that the facility does not have a written plan of supervision for these employees until their training is completed.
Plan of Correction:	Administrator will ensure all direct care staff follow the 40-Hour Direct Care Staff Curriculum, completed by RN or LPN. Administrator will ensure staff are not reflected on the daily assignment sheet or assigned to work independently until training is completed. Staff person 8 has a certificate on file from another entity noting the completion of the program on 08/08/2022, staff person 9 completed the 40-hour Direct Care Course at Runk and Pratt School of Instruction on 01/17/2025, and staff person 10 was terminated.
Standard #:	22VAC40-73-200-C
Description:	Based on staff record review and staff interviews, the facility failed to ensure that employees working as direct care staff in the facility successfully completed a department approved 40-hour direct care staff training program provided by a registered nurse or a licensed practical nurse within the first two months of employment. EVIDENCE: 1. During an on-site inspection conducted on 12/17/2024, 2 licensing inspector?s (LI?s) noted documentation of a training conducted by staff person 2 in the records for staff persons 3, 4, and 5. The certificates have documentation that the employees ?Has successfully completed the 40-hour training approved by the Virginia Department of Social Services? and ?The curriculum is based on section 22VAC40-73-200-C?. 2. In an interview with 2 licensing inspectors (LI?s) and staff person 2 conducted on-site on 12/17/2024, staff person 2 expressed that they had not been on-site in the facility to conduct the 40-hour direct care staff training for these individuals but was aware that their typed name and/or signature was on the certificates for these employees.
Plan of Correction:	Administrator/Designee will ensure Direct Care Staff complete the 40-hour Assisted Living Facility Direct Care Staff Training. The training will be provided by a registered nurse (RN) or licensed practical nurse (LPN) in the community setting, if/when the Runk and Pratt School of Instruction is unable to do so. The Runk and Pratt School of Instruction training courses are completed by Registered Nurses or Licensed Practical Nurses. This ensures that the training is conducted by a qualified licensed healthcare professional. If the Direct Care Course is unable to be completed within 2 months of employment, A Plan for Supervision of Direct Care Staff will be followed pending training completion. The following Direct Care Staff completed the 40-hour Direct Care Course at Runk and Pratt School of Instruction on 12/20/24, staff person3. Staff person 4 has a certificate on file noting completion of the Virginia Personal Care Aide 40- Hour Training through another entity dated completion 06/26/2023, and staff person 5 was terminated due to Violation of code 22VAC 90-40D.
Standard #:	22VAC40-73-200-E
Description:	Based on staff record review, review of the facility employee schedule and staff interviews, the facility failed to develop and implement a written plan for supervision of direct care staff who have not yet met the requirements for training/qualifications for direct care staff. EVIDENCE: 1. The records for staff persons 3, 4, 5, 8, 9 and 10 do not have documentation that they have completed a department approved 40-hour direct care training program provided by a registered nurse or licensed practical nurse. The facility daily assignment logs from 11/03/2024 to 12/16/2024 contains documentation of these staff persons working independently in a direct care staff capacity. 2. In an interview with 2 licensing inspectors (LI?s) and staff persons 1 and 2 on 12/17/2024, staff persons 1 and 2 confirmed that these individuals are working without supervision as direct care aides. Staff persons 1 and 2 also expressed that the facility did not have a written plan for supervision of direct care staff who have not yet met the requirements for training/qualifications for direct care staff.
Plan of Correction:	Administrator/Designee has developed and implemented a written plan for supervision of direct care staff who have not yet met the requirements. This plan identifies staff pending training completion, supervisory structure, responsibilities and guidelines, staff training and development, monitoring and evaluation, documentation and conclusion. Once the required 40-hour direct care training is completed, the direct care staff member will be capable of handling the responsibilities of their position.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review and staff interview, the facility failed to ensure the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The record for staff person 8, date of hire 11/12/2024, did not contain a criminal history record report. 2. During on-site inspection on 12/17/2024, interview with staff person 7 revealed she would reach out to corporate to obtain the criminal history record report for staff person 8. 3. As of 02/12/2025, documentation of a criminal history record report has not been provided for staff person 8.
Plan of Correction:	Administrator or Designee will ensure that staff criminal history record is on file for each employee prior to the 30th day of employment. This staff member has a Criminal History Record Name Search Request on file dated 11/12/2024, a Virginia State Police Detail Report Received 12-06-2024 showing ?Searching? as the status and a Commonwealth of Virginia Department of State Police Civil and Applicant Records Exchange with a received date at 12/10/2024. This had not been filed at the time of this inspection but had been reviewed.
Standard #:	22VAC40-90-40-D
Description:	Based on staff record review and document review, the facility failed to ensure that an employee has not been convicted of any of the barrier crimes when a criminal history record was requested. EVIDENCE: 1. The document, ?Barrier Crimes for Licensed Assisted Living Facilities and Adult Day Care Programs? dated October 2023, states that an assisted living facility cannot hire anyone who has a conviction for an offense in clause (i) of the barrier crime definition in 19.2-392.02 of the Code of Virginia. 2. The record for staff person 5, date of hire 07/03/2024, contained a Virginia criminal record, that staff person 5 was found guilty of a felony barrier crime on 06/25/2010 that is listed on the document ?Barrier Crimes for Licensed Assisted Living Facilities and Adult Day Care Programs?.
Plan of Correction:	Administrator or Designee will ensure that staff employed by the licensed assisted living have met the requirements for the barrier crimes outlined in the Virginia Code. Staff person 5 was terminated.