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: June 25, 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: 06/25/2025 8:53AM to 3:05PM 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 05/30/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 95 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: 2 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 #:	22VAC40-73-300-B
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that a method of written communication shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by resident, including complaints and incidents or injuries related to physical or mental conditions, the record shall be kept of the written communication for at least the past two years, and the information shall be included in the records of the involved residents. EVIDENCE: 1. Documentation provided by staff person 1 via email on 06/26/2025 to the licensing inspector (LI) revealed that resident 1 was hospitalized from 10/28/2024 to 10/30/2024 due to an admission of encephalopathy, UTI, and AKI; however, facility staff progress notes provided to the LI during on-site inspection on 06/25/2025 did not contain documentation that the resident was hospitalized from 10/28/2024 to 10/30/2024. An interview with staff person 1 revealed to the LI that it was not included in the facility?s communication log. 2. Facility staff notes contain documentation, dated 01/01/2025 at 6:31AM, that the resident has symptoms of the flu throwing up and loose stool. The record for resident 1 contains emergency department discharge instructions, dated 01/01/2025 at 12:18PM, that the resident was at the emergency department and was diagnosed with diarrhea and cognitive impairment. During on-site inspection, staff person 1 was unable to provide the LI anything from the facility?s written communication log that included information that the resident had been to the ER on 01/01/2025.
Plan of Correction:	Administrator/designee will ensure that documentation is updated in the written log pertaining to residents for communication between staff members. Date of Correction: 6/26/2025
Standard #:	22VAC40-73-470-A
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure, either directly or indirectly, that the health care service needs of residents are met. EVIDENCE: 1. The record for resident 1 contains a clinician visit progress note, electronically signed and dated 12/10/2024, that the resident was seen by the physician on this date for edema of left hand. The record for the resident also contains a signed physician?s order, dated 12/10/2024, to please fit resident with compression glove of left hand. 2. Staff person 2 revealed to the licensing inspector (LI) during an interview on 06/25/2025 that the resident was never fit for a compression glove nor did the resident ever have a compression glove.
Plan of Correction:	Administrator/designee will ensure the needs of the residents are met for health care services indirectly and directly. Date of Correction: 6/26/2025
Standard #:	22VAC40-73-560-E
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure all resident records shall be kept current and retained at the facility. EVIDENCE: 1. The record for resident 1 contained a signed physician?s order, dated 09/10/2024, for home health speech therapy ? 1x a week for 1 week, 2x a week for 2 weeks and 1x a week for 6 weeks. The licensing inspector (LI) asked to review the speech therapy notes for the resident. The LI received the home health notes via email from staff person 1; however, staff person 1 stated the facility had to reach out to obtain the notes as they were not available in the facility to send to the LI. 2. The record for resident 1 contained an orders reconciliation report from the hospital that was signed by a hospital physician on 10/30/2024. The LI asked staff person 1 if these signed physician?s orders were from a hospitalization as the record didn?t contain that information. Staff person 1 gave additional notes to the LI for review about the hospitalization; however, staff person 1 stated she had to reach out to the hospital and obtain the notes as they were not available in the facility during the on-site inspection. 3. The record for resident 1 contained a staff progress note, dated 01/25/2025 at 2:40PM, that the resident was complaining of neck pain, went to give PRN and help adjust and resident started crying to the touch of her neck, called responsible party and an agreement to send resident to ER was reached. During on-site inspection on 06/25/2025, the record for resident 1 did not contain any documentation about the ER visit. Staff person 1 gave documentation to the LI regarding the ER visit; however, staff person 1 stated she had to reach out to the hospital and obtain the notes as they were not available in the facility during the on-site inspection.
Plan of Correction:	Administrator/ designee will ensure residents records are kept current and retained at the facility. Date of Correction: 6/26/2025
Standard #:	22VAC40-73-650-F
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure whenever a resident is admitted to a hospital for treatment of any condition, the facility shall obtain new orders for all medications and treatments prior to or at the time of the resident?s return to the facility and the facility shall ensure that the primary physician is aware of all medication orders and has documented any contact with the physician regarding the new orders. EVIDENCE: 1. Staff person 1 emailed the licensing inspector (LI) hospital discharge documentation for resident 1 from a hospitalization the resident had from 10/28/2024 to 10/30/2024. The documentation contains a statement that the resident is to continue medications as before this hospital stay and the only additional medication is ciprofloxacin 500MG twice a day for 5 days to treat urinary tract infection. 2. Staff person 1 revealed that the record for resident 1 does not contain any documentation that the resident?s physician was contacted about the order for ciprofloxacin or the resident?s hospitalization.
Plan of Correction:	The facility will obtain new orders for medications and treatments following hospitalization and make the primary physician aware of medication orders. Contact between facility and physician will be documented. Date of Correction: 7/1/2025
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on resident record review, the facility failed to ensure medications were administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. Staff person 1 emailed the licensing inspector (LI) hospital discharge documentation for resident 1 from a hospitalization the resident had from 10/28/2024 to 10/30/2024 which was electronically signed by a physician on 10/30/2024 at 10:02AM. The hospital discharge documentation contained a statement that the resident was to continue medications as before this hospital stay and the only additional medication is ciprofloxacin 500MG twice daily for 5 days to treat urinary tract infection. The resident?s October and November 2024 medication administration records (MARs) do not contain documentation that the resident was administered ciprofloxacin 500MG twice daily for 5 days. Interview with staff person 1 confirmed this is accurate. 2. The record for resident 1 contained a signed physician?s order, dated 09/27/2024, to change Prednisone to 5MG by mouth every day, (the resident was previously prescribed Prednisone 7.5MG by mouth daily), however, the October 2024 MAR for the resident contains documentation that the resident was administered Prednisone 7.5MG daily at 8:00AM instead of 5MG daily at 8:00AM. 3. The record for resident 1 contained a signed physician?s order, dated 09/19/2024, to discontinue Lisinopril daily; however, the resident?s October 2024 MAR contains staff initials for administering Lisinopril 20MG at 8:00AM from 10/01/2024 to 10/16/2024 and 10/18/2024 to 10/28/2024 even though the medication had been discontinued.
Plan of Correction:	Administrator/ designee will ensure medications are administered according to the prescriber?s orders following the instructions and documented accurately. Administrator/designee will review MARs/prescribing orders for consistency and accuracy. Date of Correction: 7/1/2025
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) included dates the medication is discontinued or changed. EVIDENCE: 1. Resident 1?s September 2024 MAR provided to the licensing inspector (LI) by staff person 1 during on-site inspection on 06/25/2025 contains a black, thick line crossing out the following medications: Prednisone 5MG tablet take 1.5 tablets = 7.5MG by mouth daily at 8:00AM and Lisinopril 10MG take 2 tablets = 20MG daily at 8:00AM Resident 1?s October and November 2024 MARs provided to the LI by staff person 1 during on-site inspection on 06/25/2025 contains a black, thick line crossing out the following medications: Lisinopril 10MG take 2 tablets = 20MG daily at 8:00AM, Hydroxyzine HCL 25MG take one tablet two times daily at 8:00AM and 8:00PM, and Acetaminophen 325MG take two tablets = 650MG every six hours at 12:00AM, 6:00AM, 12:00PM, and 6:00PM, Acetaminophen 325MG take two tablets = 650MG every four hours as needed, and Tramadol HCL 50MG take one tablet every four hours as needed. 2. The LI was informed during the on-site inspection on 06/25/2025 that staff person 1 spoke with staff person 2 regarding the aforementioned medications that had been marked through and staff person 2 stated that the medications would have been marked through due to the medications having been discontinued. The September, October and November 2024 MARs do not contain information on the MARs that the aforementioned medications had been discontinued. Staff person 1 confirmed this is accurate.
Plan of Correction:	The administrator/designee will ensure documentation of discontinued medications are obtained. Date of Correction: 6/26/2025