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: Feb. 28, 2025

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 02/28/2025 9:20AM to 10:05AM 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: 33 assisted living level, 73 independent living level Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: medication carts 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 #:	22VAC40-73-660-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 1, dated 06/28/2024 indicates that the resident requires her medications to be administered/monitored by lay person ? registered medication aide and/or nurse. 2. During on-site inspection on 02/28/2025, the licensing inspector (LI) and staff person 1 observed a container of Hydrocortisone cream and two bottles of dry-eye eye drops sitting on the side table beside the recliner resident 1 was sitting in. During an interview with resident 1, the resident informed the LI and staff person 1 that she uses the Hydrocortisone cream daily on her legs due to her legs being itchy and dry and she uses the eye drops once a day. 3. The record for resident 1 does not contain an order that the resident can have and self-administer the medication. Interview with staff person 1 confirmed this is accurate.
Plan of Correction:	Corrective Actions: 1. Immediate Actions Taken: Assessment Review: We will conduct an immediate review of the Uniform Assessment Instruments (UAls) for all residents who are permitted to self- administer medications to ensure that only those who are appropriately assessed are st-0ringmedications in their rooms. Securing Medication: Any medication stored inappropriately or accessed by other residents will be removed form the resident's room, and proper secure storage methods will be implemented immediately. 2. Resident Education and Training: Staff Education: All staff will receive additional training on the facility's policy regarding medication storage, ensuring that they understand how to monitor and enforce medication security. This will include steps to identify potential risks and how to address them promptly. 3. Medication Storage Plan: Inspection Process: Staff will conduct routine checks to verify that residents who store medications in their rooms are in compliance with the facility's policies. Timeline for Corrective Actions: ? Resident and Staff Training (Completed within 60 days): ? Conduct a training session on medication storage practices and self- administration protocols for both residents and staff. ? Ongoing Monitoring (Initiated immediately and ongoing): ? Daily monitoring of medication storage. ? Monthly audits to ensure continued compliance. 1. Resident and Family Communication: The facility will communicate the importance of proper medication storage to residents and their families, highlighting their role in keeping medications secure and the facility's responsibility to ensure their safety.