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: April 22, 2025

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/22/2025 8:50AM to 3:30PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/03/2025 regarding allegations in the area of: resident care and related services Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-460-F
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure to notify the next of kin, legal representative, designated contact person, or, if applicable, any responsible social agency of any incident of a resident falling, whether or not it results in injury, this notification shall occur as soon as possible but no later than 24 hours from the time of initial discovery or knowledge of the incident and the resident?s record shall include documentation of the notification, including date, time, caller, and person or agency notified. EVIDENCE: 1. The record for resident 1 contains a resident incident report, dated 07/29/2924 at 7:30PM, that the resident had informed staff that he was attempting to put Ensures in his refrigerator, Ensure fell on the floor, he bent over to pick it up and fell and the incident report contains documentation that the resident was assessed for injuries and was lifted from the floor to his dining room chair. 2. The record for resident 1 does not contain documentation of notification to the resident?s next of kin, legal representative, or designated contact person. 3. Interview on 04/22/205 with staff persons 1 and 2 confirmed this is accurate.
Plan of Correction:	Administrator conducted an inservice for direct care staff for the facility will notify next of kin/ legal representative of any incident of falls within 24 hours and document in resident?s record. Date of Correction: 4/30/25
Standard #:	22VAC40-73-580-F
Complaint related:	Yes
Description:	Based on resident record review and staff interview, the facility failed to ensure to implement interventions as soon as a nutritional problem is suspected, and the interventions shall include weighing residents at least monthly to determine whether the resident has significant weight loss (i.e., 5.0% weight loss in one month, 7.5% in three months, or 10% in six months); and notifying the attending physician if a significant weight loss is identified in any resident who is not on a physician-approved weight reduction program and obtaining, documenting, and following the physician?s instructions regarding nutritional care. EVIDENCE: 1. The record for resident 1 contains a nutrition progress note, dated 09/11/2024, that based on Collateral 2?s review of resident 1?s record on this date, Collateral 2 recommended that the facility make the resident?s provider aware of the resident?s recent significant weight loss. 2. During on-site inspection on 04/22/2025, the licensing inspector (LI) was provided a monthly weight log by staff persons 1 and 2 that contains documentation that the resident?s weight was 233.8lbs in October 2024, 234.2lbs in November 2024, and 234lbs in December 2024. The LI was also provided with a document printed from the facility?s electronic medical system that contains documentation that the resident?s weight was 198.6lbs on 01/08/2025 at 2:16PM, 199lbs on 02/25/2025 at 11:12AM, 197lbs on 03/04/2025 at 12:38PM, 196.6lbs on 03/12/2025 at 9:37AM, 195lbs on 03/19/2025 at 2:12PM, 195.2lbs on 03/20/2025 at 9:25AM, and 195.2lbs on 03/31/2025 at 11:45AM. A discharge summary in the record for resident 1 from Collateral 1, dated 02/24/2025 at 9:11AM, contains documentation that the resident?s weight was 197.6lbs. 3. The resident?s documented weight of 234lbs in December 2024 and 198.6lbs on 01/08/2025 is greater than 5% weight loss in one month; however, the record for resident 1 contains a document, ?MD WEIGHT NOTIFICATION FORM?, that the resident?s primary physician was not notified of the resident?s weight loss until 03/25/2025. Interview with staff person 2 confirmed this is accurate.
Plan of Correction:	Administration/ designee will obtain weights per physician order and any significant weight changes will be reported to the physician. Date of correction: 5/22/25
Standard #:	22VAC40-73-650-B
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure that physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications, and dietary supplements shall include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often the medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. EVIDENCE: 1. The record for resident 1 contains a signed physician?s order, dated 06/07/2024, with the following statement: ?Patient may have nutritional supplement of choice in his room and eat/drink as he desires?. 2. The aforementioned physician?s order does not include the route, dosage, how often the resident may have the supplement, nor does the order identify the diagnosis, condition, or specific indications for administration of the nutritional supplement.
Plan of Correction:	Obtain order to include route, dosage, how often the resident may have the supplement, diagnosis, condition, and specific indication for administration. The facility will follow physician?s or other prescribed orders of medication administration. Date of correction: 4/22/25
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
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 record for resident 1 contains a signed as needed (PRN) physician?s order, dated 06/27/2024, for Glucose 4 G tab chew 1 tablet by mouth as needed if blood sugar (BS) less than 70 ? recheck BS after 30 minutes, repeat dose until BS greater than 90, if BS less than 70 after 2 doses or unresponsive or lethargic, notify medical doctor. The December 2024 MAR for resident 1 contains documentation that on 12/06/2024 at 8:00AM the resident?s BS was 68, on 12/10/2024 at 4:28PM the resident?s BS was 59, on 12/11/2024 at 8:00AM the resident?s BS was 60, on 12/11/2024 at 11:30AM the resident?s BS was 68, and on 12/23/2024 at 8:08AM the resident?s BS was 55; however, there is no documentation on the December 2024 MAR of staff following the aforementioned as needed physician?s order for when the resident?s BS is less than 70. 2. The record for resident 1 contains a signed physician?s order, dated 01/03/2025, for Glucose 4 G tab chew 4 tablets by mouth once as needed for blood sugar (BS) less than 80 for hypoglycemia. The January 2025 MAR for resident 1 contains documentation that on 01/05/2025 at 11:45AM the resident?s BS was 16, on 01/09/2025 at 9:23AM the resident?s BS was 79, on 01/10/2025 at 3:58PM the resident?s BS was 76, on 01/12/2025 at 11:44AM the resident?s BS was 50, on 01/13/2025 at 11:27AM the resident?s BS was 53, on 01/16/2025 at 11:36AM the resident?s BS was 53 and on 01/20/2025 at 12:48PM the resident?s BS was 53; however, there is no documentation on the January 2025 MAR of staff following the aforementioned as needed physician?s order for when the resident?s BS is less than 80.
Plan of Correction:	Administrator conducted an inservice for Registered Medication Aides to follow physicians orders according to medication administration and document in the resident?s records. Date of Corrections: 4/30/25
Standard #:	22VAC40-73-680-E
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented and the documentation shall be maintained in the resident?s record. EVIDENCE: 1. The record for resident 1 contains a signed physician?s order, dated 06/07/2024, to give sliding scale insulin of Humalog with meals or Ensure but no more frequently than every 4 hours: blood sugar (BS) 200-250 ? administer 2 units of Humalog; BS 251-300 ? administer 4 units of Humalog; 301-350 ? administer 6 units of Humalog; BS 351-400 ? administer 8 units of Humalog; and BS above 400 ? administer 10 units of Humalog; resident may keep glucometer at bedside and staff are to record readings, amount, and site. The resident?s July 2024 and August 2024 paper medication administration records (MARs) contains numerous dates/times that the resident?s blood sugar (BS) was not recorded on the MARs. The resident?s September 2024 paper MAR and October 2024 paper MAR do not contain any documentation of BS readings during these two months. Interview with staff persons 1 and 2 confirmed this is accurate and could not locate any BS readings for the resident elsewhere. 2. The record for resident 1 contains a signed physician?s order, dated 06/27/2024, to check and record blood sugar (BS) as needed for hyperglycemia/hypoglycemia ? if less than 70 or greater than 400 notify medical doctor, if unresponsive call 911; see glucose order for BS less than 70. Interview with staff person 1 during on-site inspection on 04/22/2025 revealed to the licensing inspector (LI) that this as needed order would apply to every BS check/reading that is done on the resident including daily scheduled BS checks. The resident?s December 2024 MAR contains documentation that on 12/06/2024 at 8:00AM the resident?s BS was 68, on 12/10/2024 at 4:28PM the resident?s BS was 59, on 12/11/2024 at 8:00AM the resident?s BS was 60, on 12/11/2024 at 11:30AM the resident?s BS was 68, and on 12/23/2024 at 8:08AM the resident?s BS was 55 and the resident?s January 2024 MAR contains documentation that on 01/12/2025 at 11:44AM the resident?s BS was 50, on 01/13/2025 at 11:27AM the resident?s BS was 53, on 01/17/2025 at 11:09AM the resident?s BS was 63 and on 01/20/2025 at 12:48PM the resident?s BS was 53; however, staff persons 1 and 2 were unable to provide documentation of staff following the aforementioned physician?s order of contacting the resident?s physician when the resident?s BS is less than 70. The January 2025 MAR for the resident contains documentation that on 01/05/2025 at 11:45AM the resident?s BS was 16 and that the resident?s primary physician?s office was contacted; however, the record for the resident does not contain documentation of what the resident?s physician?s response was regarding the resident?s BS. The January 2025 MAR for the resident contains documentation that on 01/16/2025 at 11:36AM the resident?s BS was 53. Staff person 2 provided to the LI a fax communication sheet, dated 01/6/2025, that states ?please review blood sugars and sign attached order? in which staff person 2 stated was for the resident?s low BS reading on this date; however, staff person 2 was unable to provide documentation of what the resident?s physician reply back was regarding the fax communication. 3. The record for resident 1 contains a signed physician?s order, dated 10/09/2024, to check the resident?s blood pressure (BP) obtain and record BP 2 times daily for monitoring. The document, ?Blood Pressure Sheet?, for October 2024 for the resident contains multiple dates that the resident?s BP was not recorded at least two times daily. (additional documentation would not fit on this notice)
Plan of Correction:	Administrator conducted an inservice for Registered Medication Aides to notify the physician and document the response of the physician referring to blood sugar in the resident?s record/MAR. Blood pressure to be documented according to orders in the resident?s record/MAR. Date of correction: 4/30/25
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure the medication administration record (MAR) shall include any medication errors or omissions. EVIDENCE: 1. Interview with staff person 2 revealed that if a medication staff person has circled their initials on a MAR, that indicates that the medication was not administered. 2. The July 2024 paper MAR for resident 1 contains numerous days that the resident?s prescribed/scheduled 8:00PM Toujeo Solostar insulin, 8:00PM Breztri Aeroshphere Inhaler and 8:00PM Flonase nasal spray contained a circle by medication administration staff as not being administered. Staff person 1 informed the licensing inspector (LI) that they were unable to locate the back of the July 2024 paper MAR to show why the resident was not administered these medications. 3. The September 2024 paper MAR for resident 1 contains numerous days that the resident?s prescribed/scheduled 8:00AM Polyethylene Glycol and 8:00PM Flonase nasal spray contained a circle by medication administration staff as not being administered; however, there were 18 instances of medication administration staff persons circling their initials for Polyethylene Glycol and 12 instances of medication administration staff persons circling their initials for Flonase nasal spray; however, the MAR did not contain documentation as to why the medications were not administered on these dates. 4. The record for resident 1 contains a signed physician?s order, dated 06/07/2024, to give sliding scale insulin of Humalog with meals or Ensure but no more frequently than every 4 hours: blood sugar (BS) 200-250 ? administer 2 units of Humalog; BS 251-300 ? administer 4 units of Humalog; 301-350 ? administer 6 units of Humalog; BS 351-400 ? administer 8 units of Humalog; and BS above 400 ? administer 10 units of Humalog; resident may keep glucometer at bedside and staff are to record readings, amount, and site. The resident?s December 2024 MAR indicates that on 12/01/2024 at 8:00AM the resident?s BS was 208 and at 11:30AM the resident?s BS was 209; however, the MAR does not contain documentation of how many units of the medication was administered to the resident. 5. The record for resident 1 contains a signed physician?s order, dated 02/19/2025, to give sliding scale insulin of Lispro before meals and at bedtime per the following sliding scale order: if BS less than 60, call MD; if BS 60 to 150, give 0 units; if BS 151 to 199, give 1 unit; if BS 200 to 249, give 2 units; if BS 250 to 299, give 3 units; if BS 300 to 349, give 4 units; if BS 350 to 400, give 5 units; if BS is greater than 400, call medical doctor. The resident?s February 2025 MAR contains documentation that the resident?s BS on 02/27/2025 at 7:33AM was 349 and at 11:55AM was 359 and on 02/28/2025 at 10:59AM was 242; however, the MAR does not contain documentation of how many units of insulin was administered to the resident. The resident?s March 2025 MAR contains numerous dates that the resident was to be administered insulin based on the sliding scale insulin order; however, the MAR does not contain documentation of how many units of insulin was administered to the resident. 6. The record for resident 1 contains a signed physician?s order, dated 04/02/2025, for insulin Lispro check BS before meals and at bedtime and inject per sliding scale insulin: 60-199 = 0 (zero) units; 200-299 = 4 units; 300-400 = 8 units and to notify medical doctor if BS is less than 60 or greater than 400. The resident?s April 2025 MAR contains numerous dates that the resident was to be administered insulin based on the sliding scale insulin order; however, the MAR does not contain documentation of how many units of insulin was administered to the resident.
Plan of Correction:	Adminstrator conducted an inservice for Registered Medication Aides to document in the resident?s MAR how many units of insulin is being adminstered following the sliding scale insulin order and medication administration documentation shall include any omissions and reasons for not administering medications. Inservice included notifying the physician of abnormal blood sugar parameter per physician orders. Date of Correction: 4/30/25