Virginia DSS · Assisted Living Facility

Runk & Pratt Residential Adult Care of Lynchburg

📍 20212 Leesville Road, Lynchburg, VA, 24502

ID 44679Two Year licenseActive
30
Inspections
On record
12
With violations
Visits that cited something
18
Clean visits
Nothing cited
35
Violations cited
Individual findings
25
Standards cited
Distinct rules
15
Complaint visits
Prompted by a complaint

Runk & Pratt Residential Adult Care of Lynchburg was inspected 30 times between December 10, 2020 and May 28, 2026 by the Virginia Department of Social Services. 12 of those visits ended with violations cited and 18 with none. Across that history VDSS cited 35 violations under 25 distinct standards. 15 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 28 of these 30 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
07/31/2026
Administrator
Alice Bryant
Licensing inspector
Cynthia Ball
Inspector phone
(540) 309-2968
Approved for
Non-Ambulatory · Assisted Living · Special Care Unit

Inspection History

30

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

May 28, 2026Inspection5 violations
Inspection dates
05/28/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1- (37) REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2- (1) GENERAL PROVISIONS63.2- (16) PROTECTION OF ADULTS AND REPORTING63.2- (17) LICENSURE AND REGISTRATION PROCEDURES63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/28/2026 8:00am until 2:30pm 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: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-870-A
on observations of the facility physical plant, the facility failed to maintain the interior in good repair.
Evidence
  1. The air conditioning cover to the unit in room 103 was observed to be loose from the right side of the wall.
  2. The mirror over the bathroom sink in room 148 was observed to be broken and pieces of wood were lying on the floor under the sink.
  3. Several stained ceiling tiles were observed on the ceiling in the large activity room near room 110.
  4. Drywall damage was observed on the ceiling by the exit sign in the hallway near rooms 117 and 118.
  5. A raised area was observed in the carpet in the hallway near rooms 177 and 188 and the carpet tiles were observed to be loose from the floor.
Plan of correction
The Maintenance Director/Designee will repair the air conditioner cover to unit in room 103. The mirror in 148 will be repaired. Stain ceiling tiles will be repaired/replaced in the activity room. Dry wall damage on ceiling by exit sign near room 117/118 will te repaired. The raised area in the carpet area in the hallway near 117/118 will be repaired. The Maintenance Director/Designee will ensure the interior of the facility's physical plant will be maintained in good repair.
22VAC40-73-680-I
Based on resident record review, the facility failed to ensure that all required information was documented on medication administration records (MARs).
Evidence
  1. The record for resident 1 has a physician order dated 05/10/2026 for Insulin Aspart 100units/ml check blood sugar three times a day and inject units three times a day with meals per sliding scale insulin. The May 2026 MAR for resident has staff initials for the administration of the sliding scale insulin for multiple days and times but does not include the number of units of insulin that was given or the location of the injection for many of the day/times.
Plan of correction
The Director of Nursing corrected the resident 1 MAR to include the number of units of insulin and location of the injection. May 28,2026 The Administrator/Director of Nursing will in-service RMAs on proper documentation on MAR going forward for medication administration documentation of sliding scale insulin.
22VAC40-73-860-I
Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area.
Evidence
  1. A container of Amazon Basics Disinfecting Wipes was observed sitting in an unlocked vanity in the hallway off of the main lobby at 9:30am on the day of on-site inspection.
Plan of correction
The container of Amazon Basics Disinfecting Wipes was removed out of the unlocked vanity in the main hallway during the on site inspection.
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure that individualized service plans (ISPs) were updated to reflect changes in residents condition.
Evidence
  1. The record for resident 4 has documentation of a physician order dated 10/12/2025 for home health services for wound care. Home Health notes in the record for resident 4 has documentation that the resident is still receiving wound care services. The ISP dated 03/25/2026 in the record for resident 4 does not include Home Health services for wound care needs.
Plan of correction
The Administrator/Designee will update resident 4 ISP to include Home Health Services for wound care. All resident's ISPs will be updated at least once every 12 months and as needed for any changes.
22VAC40-73-460-H
Based on resident record review, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met.
Evidence
  1. The individualized service plan (ISP) dated 04/17/2026 in the record for resident 1 has documentation that staff will provide physical assistance with bathing and mechanical assistance with grab bars and bench seat 2 times weekly and PRN. The bathing log for May 2026 for resident 1 does not have documentation that the resident has received a shower/bath since 05/17/2026.
Plan of correction
The Administrator /Designee will monitor the adl record weekly to ensure resident 1 receives showers/baths twice weekly and as needed, documentation will be reflected on the adl record
May 28, 2026Inspection1 violation
Inspection dates
05/28/2026
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 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: 05/28/2026 8:00am until 2:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 05/25/2026 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were: Administrative and administrative services A violation notice was issued; any violation(s) not related to the self-report 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on resident record review, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. The record for resident 1 has documentation in resident summary notes that resident 1 was observed on the floor on 05/16/2026. The notes have documentation that resident 1 sustained injuries to the right side of her forehead with slight bleeding and a skin tear on the right top of arm near her elbow. Resident 1 was sent to the local emergency room via EMS services for further evaluation due to head injury. A report of this incident was not received by the regional licensing office until 05/25/2026.
Plan of correction
The Administrator or Designee will report to the regional office within 24 hours any major incident that has a negative effect or that threatens the life, health, safety, or welfare of any resident.
January 14, 2026Inspection2 violations
Inspection dates
01/14/2026
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 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: 1/14/2026 09:30 am – 11:00 am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident) was received by VDSS Division of Licensing on 12/29/2025 regarding allegations in the area(s) of: Resident care and related services Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were: admission, retention and discharge of residents and residents care and related services. A violation notice was issued; any violation(s) not related to the self-report 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-325-C
Based on a resident record review, the facility failed to ensure that should a resident who meets the criteria for assisted living care fall, the facility must show documentation of an analysis of the circumstances of the fall.
Evidence
  1. The licensing inspector received a self-reported incident via email on 12/29/2025 regarding resident 1 who had an unwitnessed fall on 12/28/2025. During the on-site inspection conducted on 01/14/2025 the record for resident 1 did not contain documentation of an analysis of the circumstances of the fall.
Plan of correction
The Administrator in-serviced the Nurse/ RMA's on documentaticn on fall analysis. The analysis will include the circumstances of the fall and interventions initiated to reduce risk of subsequent falls on residents.
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure that individualized service plans (ISP) were updated as needed for change in resident’s condition.
Evidence
  1. The record for resident 1 has a physician’s order signed on 01/08/2026 for a bed alarm while in bed and a chair alarm while in chair. The ISP dated 6/19/2025 in the record for resident 1 was not updated to reflect the resident’s need for a bed and chair alarm as of the on-site inspection on 01/14/2026.
Plan of correction
On the day of inspection, Resident's ISP was updated to reflect the resident's need for a bed and chair alarm. The administrator/designee will do random audits to ensure resident needs are updated and identified on the resident ISP.
January 14, 2026Complaint survey0 violations
Inspection dates
01/14/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 01/14/2026 9:30am until 11:00am 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 10/31/2025 regarding allegations in the area(s) of: Resident care and related services Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 4, 2025Inspection6 violations
Inspection dates
04/04/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
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: 04/04/2025 8:30am until 1pm 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: 39 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-250-D
Based on staff record review, the facility failed to ensure that staff submitted a screening for tuberculosis on or within seven days prior to the first day of work.
Evidence
  1. The record for staff person 2, first day of work on 02/17/2025, has documentation that a screening for tuberculosis was not completed until 02/24/2025.
Plan of correction
The Administrator or Designee shall ensure that the screening for tuberculosis is done on or within 7days prior to the first day of work. DOC 4/11/2025
22VAC40-73-660-B
Based on observations of the facility physical plant and resident record review, the facility failed to ensure that a resident may be permitted to keep his own medication in an out-of-sight place in his room only if the uniform assessment instrument (UAI) has indicated that the resident is capable of self-administering medication.
Evidence
  1. A tube of Aspercreme Original, a tube of Prosacea Rosacea Gel, a tube of CVS Health Max Strength Antibiotic Pain and Scar cream, a bottle of Equate Nasal Spray and several Halls Cough drops were observed sitting out on a bed side table in the room for resident 2. The record for resident 2 does not have a physician order for these medications.
  2. The history and physical dated 03/04/2024 has documentation that resident 2 is not capable of administering their own medications. The UAI dated 02/25/2025 in the record for resident 2 has documentation that medications are administered by a Layperson.
Plan of correction
Removed contents day of inspection 04/04/2025. MD order obtain to self-administer medications for the following tube Aspercream original, a tube of Prosacea Rosacea Gel, CVS Health max Strength Antibiotic Pain and scar cream, a bottle of Equate Nasal Spray and several Halls cough drops. DOC 04/14/2025 The resident's UAI and care plan will reflect MD order to self-administer. DOC DOC 04/14/2025
22VAC40-73-1070-B
Based on observations of the facility physical plant, the facility failed to ensure that when there are indications that ordinary materials or objects may be harmful to residents with a serious cognitive impairment, these materials or objects shall be inaccessible to the residents except under staff supervision.
Evidence
  1. The door to room 128 was observed to be propped open at 9am on the day of on-site inspection and the room was unattended. A can of Lysol Disinfectant spray was observed sitting out on a mini-fridge in the room. The facility has a mixed population of residents, some of whom has serious cognitive impairments.
Plan of correction
Lysol Disinfectant spray was removed at time of inspection on 04/04/2025. The Administrator /Designee will ensure that all chemicals and hazardous materials are stored in a locked area . Routine rounds will be made to ensure that hazardous materials/ chemicals are not available/within reach. DOC 4/04/2025
22VAC40-90-30-B
Based on staff record review, the facility failed to ensure that a sworn statement or affirmation was completed for all applicants for employment.
Evidence
  1. The record for staff person 2, hire and first day of work on 02/17/2024, has documentation that a sworn statement or affirmation was not completed by this employee until 02/24/2025.
Plan of correction
The Administrator/Designee will ensure that the sworn statement or affirmation shall be completed for all applicants prior to hire date. DOC 04/11/2025
22VAC40-73-325-B
Based on resident record review, the facility failed to ensure that a fall risk rating was completed after a fall for residents who are assessed ad assisted living level of care.
Evidence
  1. The record for resident 4 has documentation of the resident falling on 09/02/2024 and on 01/26/2025. The last fall risk rating completed for this resident was dated 08/01/2024. The uniform assessment instrument (UAI) dated 08/01/2024 in the record for resident 4 has documentation that resident 4 is assisted living level of care.
Plan of correction
The Administrator /Designee will ensure that the fall risk rating shall be reviewed and updated after a resident has a fall. DOC 04/11/2025
22VAC40-73-680-D
Based on observations of the morning medication pass conducted at 9:25am on 04/04/2025 and staff interviews, the facility failed to ensure that medications were administered in accordance with physician instructions.
Evidence
  1. The March 2025 medication administration record (MAR) for resident 1 has documentation of a physician order for Furosemide 20mg, 1 tab by mouth every day. During observations of the morning medication pass for resident 1, it was observed by staff person 1 that the Furosemide 20mg medication was not in the cart for resident 1. Staff person 1 then located a bubble pack for resident 1 that contained Furosemide 20mg in the PRN drawer of the medication cart. Staff person 1 expressed that the Furosemide 20mg order for resident 1 had changed to PRN. Staff person 1 did not administer the medication to resident 1 and documented on the medication administration record (MAR) for 04/04/2025 at 10:00 “change documentation”.
  2. A review of signed physician orders for resident 1 has documentation that the Furosemide 20mg, 1 tab by mouth daily was signed on 09/03/2024 and has not been changed. There is also a signed physician order dated 09/03/2024 for Furosemide 20mg can take one more tab as needed.
Plan of correction
Lasix ordered 04/04/2025 and arrived on 04/05/2025. Meds will be administered according to physician's order. Routine cart audits to be performed by Administrator/Designee. DOC 04/05/2025
April 4, 2025Inspection0 violations
Inspection dates
04/04/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: 04/04/2025 8:30am until 1:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 01/24/2025 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 39 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 10, 2025Inspection3 violations
Inspection dates
01/10/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION
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: 01/10/2025 8:55am until 10:30am 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: 46 Number of staff records reviewed: 13 Number of interviews conducted with staff: 2 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-200-C
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 01/10/2025, the record for staff person 1, hired on 08/13/2024, had documentation of a training certificate conducted by staff person 4, who is a licensed practical nurse, with a completion date of 08/23/2024. The certificate has documentation that staff person 1 “Has successfully completed the 40-hour training approved by the Virginia Department of Social Services” and “This curriculum is based on section 22VAC40-73-200-C”. The record for staff person 2, hired on 10/08/2024, had documentation of a training certificate conducted by staff person 4, who is a licensed practical nurse, with a completion date of 10/16/2024. The certificate has documentation that staff person 2 “Has successfully completed the 40-hour training approved by the Virginia Department of Social Services” and “This curriculum is based on section 22VAC40-73-200-C”.
  2. In an interview with staff person 4 and both LI’s conducted on 12/05/2024, staff person 4 expressed that they had not been on-site in any facility to conduct the 40-hour direct care staff training for any employee. In an interview with both LI’s and staff person 3 conducted on 01/10/2025, staff person 3 explained that the training for these individuals was on the floor with other direct care staff employees. These employees are not registered nurses or licensed practical nurses.
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 Person #1 and Staff Person #2 completed on 1/17/2025.
22VAC40-73-150-C
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 01/10/2025, staff persons 1 and 2 hired during staff person 3’s time as the facility administrator were noted to be on the facility daily assignment sheets working as direct care staff. In an interview conducted on 01/10/2025 with both LI’s and staff person 3, staff person 3 confirmed that the direct care training that staff person 1 completed on 08/23/2024 and staff person 2 completed on 10/16/2024 did not follow the department approved curriculum as the curriculum was not available in the facility and was not provided by a registered nurse or licensed practical nurse, which does not meet the requirements of 22VAC40-73-200-C-7. Staff person 3 expressed that training provided during their employment as the facility administrator has been on the floor training with another direct care staff member.
  2. During on-site inspection conducted on 01/10/2025, staff person 2, hired on 10/08/2024 who has not yet met required training as outlined in standard 22VAC40-73-200-C-1 through 7 was noted to be on the facility daily assignment sheets working independently as direct care staff. Staff person 3 confirmed that the facility does not have a written plan of supervision for these employees until their training is completed.
Plan of correction
Staff person #1 has training by MBN on 8/23/2024 and completed the 40 hour class on 12/20/2024 by Runk and Pratt School of Instruction Staff person #2 has training by MBN on 10/16/2024 and has completed the 40 hour class on 1/17/2025 by Runk and Pratt School of Instruction. 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. - January 17, 2025
22VAC40-73-200-E
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 record for staff person 2 does 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 employee schedule from 12/15/2024 through 01/11/2025 has documentation that this employee was scheduled to work independently in a direct care staff capacity. In an interview with 2 LI’s and staff person 3, staff person 3 could not verify that staff person 2 has completed the required training but confirmed that staff person 2 is working without supervision as a direct care aide. Staff person 3 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. March 3, 2025
January 10, 2025Inspection0 violations
Inspection dates
01/10/2025
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: 01/10/2025 8:55am until 10:30am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 11/08/2024 regarding allegations in the area(s) of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 46 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 10, 2025Complaint survey0 violations
Inspection dates
01/10/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 01/10/2025 8:55am until 10:30am 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 12/10/2024 regarding allegations in the area(s) of: Administration and administrative services, resident care and related services Number of residents present at the facility at the beginning of the inspection: 46 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 2, 2024Inspection1 violation
Inspection dates
10/02/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: 10/02/2024 10:00am until 11:30am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on (10/01/2024) regarding allegations in the area(s) of: Administration and administrative services, resident care and related services Number of residents present at the facility at the beginning of the inspection: 46 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were: Administration and administrative services A violation notice was issued; any violation(s) not related to the self-report 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-70-B
Based on resident record and facility documentation review, the facility failed to ensure that all required information was included in 24-hour incident reporting.
Evidence
  1. The Licensing Inspector (LI) received an email from the facility on 10/01/2024 to provide 24-hour reporting for an incident that occurred with resident 1. The 24-hour reporting did not include the date and time of the incident, the location of the incident or the name of the staff person in charge at the time of the incident.
Plan of correction
The Administrator will ensure that all required information is provided for 24-hour reporting of incidents.
October 2, 2024Inspection0 violations
Inspection dates
10/02/2024
Areas reviewed
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: 10/02/2024 10:00am until 11:30am 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: 46 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 14, 2024Inspection3 violations
Inspection dates
05/14/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/14/2024 9:00am until 3:00pm 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: 50 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-860-I
Based on observations of the facility physical plant, the facility failed to ensure that hazardous materials were stored in a locked area.
Evidence
  1. Two bottles of NUVEL Nail Polish Remover and a plastic basket with numerous bottles of finger nail polish were observed in an unlocked cabinet in the large activity room.
Plan of correction
Administrator/Designee with ensure that all chemical and hazardous materials are stored in a locked area. Routine rounds will be made to ensure that hazardous materials/chemicals are not available/within reach. DOC – May 14, 2024
22VAC40-73-1040-A
Based on observations of the facility physical plant, the facility failed to ensure that a system of security monitoring was in place on all doors leading to the outside for residents with serious cognitive impairments.
Evidence
  1. At 10:30am on 05/14/2024 the licensing inspector in the presence of staff person 4 noted that the front doors to the facility did not have a system of security monitoring in place for residents with cognitive impairments. The facility houses a mixed population of residents such as resident 3, who is assessed with disorientation to all spheres some of the time on a uniform assessment instrument (UAI) dated 06/15/2023 and resident 4 who is assessed with disorientation to some spheres some of the time with person, place and situation as spheres affected on a UAI dated 04/01/2024.
Plan of correction
The main lobby doors leading to the outside will have a system of security monitoring installed. DOC – June 14, 2024
22VAC40-73-210-B
Based on staff record review, the facility failed to ensure that direct care staff received at least 18 hours of training annually.
Evidence
  1. The record for staff person 2, hired on 01/16/2023 as a direct care aide, has documentation that this employee only received 13 hours of annual training from 01/16/2023 through 01/16/2024.
Plan of correction
Administrator/Designee will ensure that all direct care staff have 18 hours of training annually. DOC – June 1, 2024
May 14, 2024Complaint survey0 violations
Inspection dates
05/14/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/14/2024 9am until 3pm 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 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 50 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of Resident records reviewed: 1 Number of resident interviews: 3 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 23, 2024Inspection0 violations
Inspection dates
02/23/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/23/2024 9am until 11:30am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing regarding allegations in the area(s) of: Resident care and related services and additional requirements for facilities that care for adults with serious cognitive impairements Number of residents present at the facility at the beginning of the inspection: 50 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 23, 2024Inspection0 violations
Inspection dates
02/23/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/23/2024 9am until 11:30am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 50 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 23, 2024Complaint survey0 violations
Inspection dates
02/23/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/23/2024 9am until 11:30am 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 regarding allegations in the area(s) of: Staffing, resident accommodations and building and grounds. Number of residents present at the facility at the beginning of the inspection: 50 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 18, 2023Complaint survey0 violations
Inspection dates
09/18/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/18/2023 2:00pm until 3:00pm 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 regarding allegations in the area(s) of: Personnel, Staffing and resident care and related services Number of residents present at the facility at the beginning of the inspection: 59 Number of resident records reviewed: 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 did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email atcynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 8, 2023Inspection4 violations
Inspection dates
06/08/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/08/2023 8am until 2pm 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: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed:8 Number of staff records reviewed:4 Number of interviews conducted with residents:2 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on a review of resident records and medication administration records (MARs), the facility failed to ensure that medications were administered in accordance with physician instructions.
Evidence
  1. The record for resident 7 has a physician order dated 05/10/2023 for Bleph 10, 2 drops in left eye four times a day for 7 days for conjunctivitis. The May 2023 MAR for resident 7 does not have documentation of this physician order being transcribed to the MAR or documentation of staff initials for the administration of the medication. Interview with staff 5 verified that this was correct.
Plan of correction
Medications will be administered according to physician orders or other prescribers’ instructions. Administrator/Designee will ensure physician orders are faxed to the pharmacy and transcribed to the electronic MAR for administration.
22VAC40-73-870-A
Based on observations of the facility physical plant, the facility failed to maintain the interior of the building in good repair.
Evidence
  1. The Activity/Dining room was noted to have several stains on the ceiling.
  2. The Activity room near the Therapy area was noted to have ceiling stains to the right near the fire sprinkler.
Plan of correction
The facility interior will remain in good repair. Maintenance will repair the activity/dining room ceiling stains.
22VAC40-73-680-I
Based on a review of resident records and medication administration records (MARs), the facility failed to ensure that all required information was included on resident MARs.
Evidence
  1. The record for resident 5 has a physician order dated 02/08/2023 for “Oxygen @ 2L PRN for comfort if short of breath (via nasal Cannula)”. The May and June 2023 MARs for resident 5 do not have documentation of the order for oxygen.
Plan of correction
Administrator/Designee will ensure that all prescribed medications/orders will be placed and documented on the resident MAR. The oxygen order was placed on the resident MAR on 6/9/2023.
22VAC40-73-450-C
Based on a review of resident records, the facility failed to ensure that identified needs were addressed on individualized service plans (ISPs).
Evidence
  1. The record for resident 2 has a physician order dated 05/22/2023 to elevate legs when at rest every shift and to discontinue lactose intolerant on resident 2’s diet. The ISP dated 05/17/2023 in the record for resident 2 does not address the identified need for the residents legs to be elevated at rest every shift and still contains documentation that the resident is lactose intolerant.
Plan of correction
On day of inspection, Resident’s ISP was updated to reflect elevation of legs and discontinue lactose intolerance from the ISP. Random audits will be performed to ensure resident needs are updated and identified on the resident ISP.
June 8, 2023Complaint survey0 violations
Inspection dates
06/08/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/08/2023 8am until 2pm 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 03/19/2023 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident 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 did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 8, 2023Complaint survey0 violations
Inspection dates
06/08/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/08/2023 8am until 2pm 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 01/11/2023 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed:8 Number of staff records reviewed:4 Number of interviews conducted with residents:2 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 16, 2022Complaint survey0 violations
Inspection dates
09/16/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/16/2022 8:30am until 11:30am 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 07/21/2022 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 52 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 16, 2022Complaint survey0 violations
Inspection dates
09/16/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/16/2022 8:30am until 11:30am 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 07/21/2022 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 52 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 16, 2022Complaint survey0 violations
Inspection dates
09/16/2022
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/16/2022 8:30am until 11:30am 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 07/21/2022 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 52 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 25, 2022Complaint survey0 violations
Inspection dates
03/25/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
The LI for the Runk and Pratt Residential Adult Care of Lynchburg conducted a complaint inspection on 03/25/2022. A phone interview was conducted with the facility Administrator and facility records, documentation, menus and the most recent Dietician oversight for special diets was requested and reviewed. Based on a review of all evidence available for review no violations were cited during this inspection. If you have any questions or concerns please feel free to contact your LI at 540-309-2968.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 9, 2021Complaint survey0 violations
Inspection dates
12/09/2021
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION
Comments
A non-mandated complaint inspection was initiated on 12/09/2021 and concluded on 01/20/2022. A complaint was received by the department regarding allegations in the areas of staffing and resident care and related services. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on 01/20/2022. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 27, 2021Inspection2 violations
Inspection dates
09/27/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated monitoring inspection was initiated on 09/27/2021 and concluded on 10/01/2021. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported non-compliance with standards or law, and violations issued can be found on the violation notice.
Violations
22VAC40-73-680-I
Based on a review of resident medication administration records (MARs), the facility failed to ensure that all required information was documented on resident MARs.
Evidence
  1. The August 2021 MAR for resident 2 has documentation of a physician order for Novolog Flex Pen 19 units before dinner, hold for blood sugars less than 100. The MAR has documentation of resident 2's blood sugar being 81 at 4:30pm on 08/12/2021. Staff initials are present, without being circled, at 4:30pm on 08/12/2021 as administering this medication including the number "2" to reflect the injection site. The last page of the MAR is inconsistent as it has documentation that the Novolog Insulin was held due to the resident blood sugar being 81.
Plan of correction
All Registered Med Aides will be in serviced on medication administration/treatments and will include proper documentation to ensure physicians orders are being followed as prescribed and recorded in the medication records.
22VAC40-73-680-E
Based on a review of medication administration records (MARs), the facility failed to document medical procedures.
Evidence
  1. The August 2021 MAR for resident 2 has a physician order for weekly weights on Thursday for monitoring and to fax the results to the residents physician. The MAR does not have the recording of the residents weight on 08/12/2021 or 08/19/2021. The last page of the MAR has documentation that the weight was not completed due to the resident being on isolation but there is no documentation of a physician order to hold weights for these days.
Plan of correction
All Registered Med Aides will be in serviced on medication administration/treatments and will include proper documentation to ensure physicians orders are being followed as prescribed and recorded in the medication records.
September 23, 2021Complaint survey0 violations
Inspection dates
09/23/2021
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
A non-mandated complaint inspection was initiated on 09/23/2021 and concluded on 10/01/2021. A complaint was received by the department regarding allegations in the areas of staffing and resident care and related services. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 13, 2021Complaint survey1 violation
Inspection dates
09/13/2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
Comments
A non-mandated complaint inspection was initiated on 09/13/2021 and concluded on 10/01/2021. A complaint was received by the department regarding allegations in the areas of Infection Control. The Administrator was contacted by telephone to conduct the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations issued can be found on the violation notice.
Violations
22VAC40-73-100-F
Based on interviews made with facility staff, the facility failed to follow recommendations made by the Virginia Department of Health.
Evidence
  1. Positive Covid-19 cases were noted within the facility on 08/26/2021. Recommendations to complete a line list for tracking and out break testing every 14 days were made to the facility on 09/03/2021 by an Epidemiologist with the local Virginia Department of Health. Interviews with staff person 1 and 2 conducted via phone on 09/13/2021 expressed that these recommendations had not been followed up to this point.
Plan of correction
The Administrator has completed a line list for covid-19 cases and out break testing. The tracking was submitted on 9/13/21 to the epidemiologist with the local Virginia Department of Health. Administrator or designee will follow the recommendations of the Epidemiologist with the local Virginia Department of Health to prevent and/or control the spread of communicable diseases.
June 21, 2021Inspection5 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
A renewal inspection was initiated on 6/21/2021 and concluded on 6/25/2021. The Administrator was contacted by telephone to initiate the inspection. The (person in Administrator reported that the current census was 45. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 3 resident records, 3 staff records, Health care and Dietician oversight, Fire and Health Inspections and fire drill logs submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 6/25/2021. An exit interview was conducted with Administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-260-C
Based on observations made during a tour of the facility physical plant conducted on 6/25/2021, the facility failed to ensure that a listing of all staff current in first aid and/or CPR was post in the facility.
Evidence
  1. A listing of staff who are current in first aid/CPR was not posted in the facility at the time of this inspection.
Plan of correction
A list of staff who are current in First Aid/CPR was posted at time on inspection.
22VAC40-73-450-C
Based on a review of resident records, the facility failed to esure that all identified needs were addressed on individualized service plans (ISPs).
Evidence
  1. The ISP dated 6/7/21 in the record for resident 2 has documentation of home health for an identified need but does not specify what services home health is providing for the residents wound care needs.
  2. The ISP dated 5/12/21 in the record for resident 3 has documentation of home health for an identified need but does not specify what services home health is providing for the residents wound care needs. Also the record for resident 3 has a physician order to crush medications if applicable and administer in pudding, applesauce or yogurt. The ISP does not address this identified need.
Plan of correction
Resident 2 ISP has been updated to reflect specific services that home health is providing for resident wound care needs. Resident 3 ISP has been updated to reflect specific services I home health needs for wound care. Resident 3 ISP has been updated to reflect crush meds to be administered in pudding, applesauce or yogurt if applicable.
22VAC40-73-680-D
Based on a review of resident records and medication administration records (MARs), the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions.
Evidence
  1. The record for resident 3 has a physician order dated 6/11/2021 for Ibuprofen 200mg, 1 tablet my mouth twice a day for 5 days. The June 2021 MAR for resident 3 does not have documentation that this physicians order was ever transcribed to the MARs and there are no staff initials to indicate that the medication was administered.
Plan of correction
Nurse/RMA will administer meds according to physicians or other prescriber's instructions. Unit Manager or designee will ensure orders are reflected on medication record as prescribed by physician. Nurse/RMA will follow prescribed orders as indicated for medication administration. Nurse/RMA staff will be in serviced on following physician prescribed orders and medication administration record.
22VAC40-73-680-M
Based on observations of the facility medication carts conducted on 6/25/2021, the facility failed to ensure that all PRN medications ordered for a resident was available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. The record for resident 2 has a physician order for Pepto-Bismol Suspension, 30mls by mouth 4 times a day as needed for indigestion. This medication was not available on the cart on the day of inspection.
Plan of correction
Resident 2 PRN Pepto-Bismol Suspension was delivered and placed on med cart for administration as needed. United Manager or designee will ensure PRN meds are available at all times for residents as prescribed by physician thru scheduled cart audits.
22VAC40-73-870-A
Based on observations made during an on-site inspection conducted on 6/25/2021, the facility failed to maintain the exterior of the building in good repair.
Evidence
  1. A white column to the left of the front doors was noted to be broken completely from the bottom pedestal.
Plan of correction
Maintenance will repair bottom pedestal of white column to maintain the exterior of the building in good repair.
December 10, 2020Complaint survey2 violations
Inspection dates
Dec. 10, 2020
Areas reviewed
22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 12/10/2020 and concluded on 12/12/2020. A complaint was received by the department regarding allegations in the areas of resident care and related services. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-390-A
Based on a review of the record for resident 1, the facility failed to follow their resident agreement in regards to adjustment to rates.
Evidence
  1. The resident agreement in the record for resident 1 signed on 2/6/2020 has documentation under adjustment to rates located on page 6 that "the community shall have the right, upon 30 days prior written notice to you or your verbal consent due to a significant medical change, to change your room and board and/or level of care rate and other fees and charges. If your care is funded at government-prescribed rates, the operative date for any government modification in reimbursement rate shall be the operative date for a change in your level of care rate".
  2. Resident 1 and/or their legal representative received a letter from the facility dated 11/17/2020 expressing "that Runk and Pratt has worked diligently to protect residents during the Covid 19 pandemic. Until recently we have been successful in keeping our communities free of the virus. Due to the additional daily responsibilities in caring for those effected, there will be an additional daily charge of $300.00 until medically cleared by the physician". This letter gives no notice of 30 days before being charged to the resident.
Plan of correction
The Licensee will ensure a 30 day notice is given to resident/POA and or legal representative prior to any additional resident fees being accrued.
22VAC40-73-680-E
Based on a review of the record for resident 1, the facility failed to ensure medical procedures or treatments ordered by a physician were provided according to his instructions.
Evidence
  1. The record for resident 1 has a physician order dated 11/2/2020 for Knee High TED Hose to be applied every morning at 7am and removed at bedtime at 7pm. In a virtual inspection conducted with the facility administrator on 12/11/2020 at 2pm it was observed that resident 1 did not have her TED Hose on but staff initials were present on the December 2020 medication administration record for applying the TED Hose at 7am on 12/11/2020.
Plan of correction
All RMA's will be in serviced on medication administration/treatments and will include proper documentation to ensure physician orders are being followed as prescribed and recorded in medication record.