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. 14, 2025

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 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: 11/14/2025 8:41AM to 12:30PM 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 11/03/2025 regarding allegations in the areas of: administration and administrative services, personnel, resident care and related services, buildings and grounds, & emergency preparedness Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 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 some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: administration & administrative services and resident care & related services A violation notice was 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 #:	22VAC40-73-100-C-2
Complaint related:	Yes
Description:	Based on observation, facility policy review and staff interview, the facility failed to ensure its infection control program includes procedures for infection prevention measures related to job duties to include the sanitation of equipment. EVIDENCE: 1. During on-site inspection on 11/14/2025 at approximately 8:51AM, the licensing inspector (LI) and staff person 1 observed two plastic urinals sitting on the back of the toilet in resident 1?s bathroom. Staff person 1 confirmed that both urinals have been used based on the staining on the inside of both urinals. Staff person 1 stated that direct care staff use the plastic urinals with the resident due to the resident no longer being able to use the toilet and that the plastic urinals are supplied by hospice. Interview with staff person 2 confirmed that plastic urinals are considered equipment. 2. The facility?s infection control plan provided to the LI during the on-site inspection does not contain information on how staff are to clean plastic urinals. Staff person 1 confirmed this is accurate.
Plan of Correction:	Urinal policy has been created and implemented to meet the infection control program for housekeeping, direct care and nursing.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on observation, resident record review and staff interview, the facility failed to ensure individualized service plans (ISPs) shall be reviewed and updated as needed for a significant change of a resident?s condition. EVIDENCE: 1. The ISP in the record for resident 1, dated 06/11/2025, states for toileting that the resident is unable to sit on the toilet, is not toileted and direct care staff are to change the resident?s brief in his bed every 2 hours and the ISP states that the resident is bladder incontinent weekly or more, wears disposable briefs and direct care staff are to clean the resident?s skin after each episode. The record for resident 1 contains a staff note by staff person 2, dated 07/08/2025, that the resident verbalized he used his urinal and an aide reported to staff person 2 that the resident has been actively using a urinal at times. 2. During on-site inspection on 11/14/2025 at approximately 8:51AM, the licensing inspector (LI) and staff person 1 observed two plastic urinals on the back of resident 1?s toilet. Staff person 1 revealed that the urinals are used by direct care staff for resident 1 because the resident is no longer able to use the toilet. The resident?s ISP does not contain documentation that a urinal is used for the resident.
Plan of Correction:	ISP has been updated to reflect the use of the urinal device, as needed.
Standard #:	22VAC40-73-460-A
Complaint related:	Yes
Description:	Based on resident record review, staff record review and staff interview, the facility failed to assume general responsibility for the health, safety, and well-being of the residents. EVIDENCE: 1. Documentation provided by the facility to the licensing inspector (LI) states that on 06/08/2025 at 7:01AM staff person 4 was changing resident?s 1 brief when the resident rolled off the side of his bed, hit his head on the side table, and landed on the floor. Staff person 4 then picked the resident up out of the floor and placed him back in his bed. The resident was transported to the hospital and returned back to the facility the same day with multiple skin tears and a laceration to the top of his head that required 10-12 staples. 2. The individualized service plan (ISP) for resident 1, dated 01/20/2025, contains documentation that the resident is a two person assist and that two staff members are to assist with activities of daily living (ADL) care for safety. 3. During on-site inspection on 11/14/2025, documentation provided by staff person 2 to the LI, dated 06/17/2025, states that resident 1 requires two staff persons for ADL care; however, staff person 4 was the only staff person assisting the resident during ADL care on 06/08/2025. Also, the document states that staff person 4 should not have picked the resident up out of the floor and placed him back in his bed since he had fallen and hit his head and that EMS will assess and move the resident. 4. The record of initial assisted living facility staff training for staff person 4, occurring between 04/11/2025 through 04/18/2025, contains documentation that staff person 4 received training on procedures for handling resident emergencies on 04/17/2025. Staff person 3 revealed that during this training, staff who do not have first aid certification are instructed not to perform any tasks related to first aid and they are to reach out to their supervisor if there is a resident emergency, such as if a resident has fallen. Staff person 1 stated that first aid teaches that an individual should not be moved after a fall and revealed that the facility could not locate evidence that staff person 4 had first aid certification.
Plan of Correction:	Administrator/ Designee will ensure that the care plan is followed in assisting with activities of daily living. Administrator/Designee will train staff on resident emergencies in regard to moving a resident without approval/direction by licensed healthcare professional. Administrator/Designee will ensure that staff are informed to contact shift supervisor if there is a resident emergency.