16
Inspections
On record
9
With violations
Visits that cited something
7
Clean visits
Nothing cited
38
Violations cited
Individual findings
28
Standards cited
Distinct rules
5
Complaint visits
Prompted by a complaint
Runk and Pratt Willow Ridge was inspected 16 times between May 13, 2024 and March 6, 2026 by the Virginia Department of Social Services. 9 of those visits ended with violations cited and 7 with none. Across that history VDSS cited 38 violations under 28 distinct standards. 5 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.
Every inspection listed here is currently published on the VDSS site.
Provider Information
Facility type
Assisted Living Facility
License type
One Year
License expires
12/27/2026
Administrator
Patrick Hurt
Licensing inspector
Jennifer Stokes
Inspector phone
(540) 589-5216
Approved for
Non-Ambulatory · Assisted Living
Inspection History
16Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.
March 6, 2026Inspection
Inspection dates
03/06/2026
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: 03/06/2026 9:00AM to 9:25AM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
Number of resident records reviewed: 1
Number of interviews conducted with residents: 1
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
December 10, 2025Inspection
Inspection dates
12/10/2025
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: 12/10/2025 9:30AM to 10:30AM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-reported was received by VDSS Division of Licensing on 12/05/2025 regarding allegations in the area of: resident care and related services
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
November 14, 2025Complaint survey
Inspection dates
11/14/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/14/2025 8:41AM to 12:30PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by VDSS Division of Licensing on 11/03/2025 regarding allegations in the areas of: administration and administrative services, personnel, resident care and related services, buildings and grounds, & emergency preparedness
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: administration & administrative services and resident care & related services
A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.
If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview.
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area.
Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-100-C-2
Based on observation, facility policy review and staff interview, the facility failed to ensure its infection control program includes procedures for infection prevention measures related to job duties to include the sanitation of equipment.
Evidence
- During on-site inspection on 11/14/2025 at approximately 8:51AM, the licensing inspector (LI) and staff person 1 observed two plastic urinals sitting on the back of the toilet in resident 1’s bathroom. Staff person 1 confirmed that both urinals have been used based on the staining on the inside of both urinals. Staff person 1 stated that direct care staff use the plastic urinals with the resident due to the resident no longer being able to use the toilet and that the plastic urinals are supplied by hospice. Interview with staff person 2 confirmed that plastic urinals are considered equipment.
- The facility’s infection control plan provided to the LI during the on-site inspection does not contain information on how staff are to clean plastic urinals. Staff person 1 confirmed this is accurate.
Plan of correction
Urinal policy has been created and implemented to meet the infection control program for housekeeping, direct care and nursing.
22VAC40-73-460-A
Based on resident record review, staff record review and staff interview, the facility failed to assume general responsibility for the health, safety, and well-being of the residents.
Evidence
- Documentation provided by the facility to the licensing inspector (LI) states that on 06/08/2025 at 7:01AM staff person 4 was changing resident’s 1 brief when the resident rolled off the side of his bed, hit his head on the side table, and landed on the floor. Staff person 4 then picked the resident up out of the floor and placed him back in his bed. The resident was transported to the hospital and returned back to the facility the same day with multiple skin tears and a laceration to the top of his head that required 10-12 staples.
- The individualized service plan (ISP) for resident 1, dated 01/20/2025, contains documentation that the resident is a two person assist and that two staff members are to assist with activities of daily living (ADL) care for safety.
- During on-site inspection on 11/14/2025, documentation provided by staff person 2 to the LI, dated 06/17/2025, states that resident 1 requires two staff persons for ADL care; however, staff person 4 was the only staff person assisting the resident during ADL care on 06/08/2025. Also, the document states that staff person 4 should not have picked the resident up out of the floor and placed him back in his bed since he had fallen and hit his head and that EMS will assess and move the resident.
- The record of initial assisted living facility staff training for staff person 4, occurring between 04/11/2025 through 04/18/2025, contains documentation that staff person 4 received training on procedures for handling resident emergencies on 04/17/2025. Staff person 3 revealed that during this training, staff who do not have first aid certification are instructed not to perform any tasks related to first aid and they are to reach out to their supervisor if there is a resident emergency, such as if a resident has fallen. Staff person 1 stated that first aid teaches that an individual should not be moved after a fall and revealed that the facility could not locate evidence that staff person 4 had first aid certification.
Plan of correction
Administrator/ Designee will ensure that the care plan is followed in assisting with activities of daily living.
Administrator/Designee will train staff on resident emergencies in regard to moving a resident without approval/direction by licensed healthcare professional.
Administrator/Designee will ensure that staff are informed to contact shift supervisor if there is a resident emergency.
22VAC40-73-450-F
Based on observation, resident record review and staff interview, the facility failed to ensure individualized service plans (ISPs) shall be reviewed and updated as needed for a significant change of a resident’s condition.
Evidence
- The ISP in the record for resident 1, dated 06/11/2025, states for toileting that the resident is unable to sit on the toilet, is not toileted and direct care staff are to change the resident’s brief in his bed every 2 hours and the ISP states that the resident is bladder incontinent weekly or more, wears disposable briefs and direct care staff are to clean the resident’s skin after each episode. The record for resident 1 contains a staff note by staff person 2, dated 07/08/2025, that the resident verbalized he used his urinal and an aide reported to staff person 2 that the resident has been actively using a urinal at times.
- During on-site inspection on 11/14/2025 at approximately 8:51AM, the licensing inspector (LI) and staff person 1 observed two plastic urinals on the back of resident 1’s toilet. Staff person 1 revealed that the urinals are used by direct care staff for resident 1 because the resident is no longer able to use the toilet. The resident’s ISP does not contain documentation that a urinal is used for the resident.
Plan of correction
ISP has been updated to reflect the use of the urinal device, as needed.
October 21, 2025Inspection
Inspection dates
10/21/2025
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 GROUNDS22VAC40-73 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: 10/21/2025 7:40AM to 1:55PM
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: 36 assisted level of care residents
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: 4
Number of interviews conducted with staff: 5
Observations by licensing inspector: breakfast, activities, medication administration, medication cart audits
Additional Comments/Discussion:
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.
If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview.
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area.
Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-620-B
Based on resident record review and staff interviews, the facility failed to ensure action taken in response to the recommendations made by the dietitian or nutritionist who completed the six-month oversight of special diets for residents, was documented in the resident’s record.
Evidence
- The record for resident 1 contained a nutrition progress note by the registered dietitian, dated 09/30/2025, with a recommendation that the resident should have no orange juice, tomato, V8 juice, prune juice, pinto beans, tomato/spaghetti sauce, potatoes, tomato soup, bananas to help manage elevated potassium levels.
- The facility had documentation signed by the physician acknowledging the most recent special diet review conducted on 09/30/2025 which included the recommendation for resident 1; however, there was no documentation by the physician whether they agreed or disagreed with the recommendation. Interview with staff persons 1 and 2 confirmed this is accurate.
Plan of correction
Will insure that the action are taken in response to the recommendations of the Licensed Dietician/Nutritionist. Resident 1 record was correct at time of inspection.
22VAC40-73-950-E
Based on resident record review and staff interviews, the facility failed to ensure the semi-annual review on the facility’s emergency preparedness and response plan for resident shall be documented by signing and dating.
Evidence
- The most recent document provided by staff persons 1 and 2 during on-site inspection indicating that residents 1 and 4 had a review of the facility’s emergency preparedness and response plan contained the signatures of residents 1 and 4; however, the documents did not contain the date of when the review was completed. Staff persons 1 and 2 confirmed this is accurate.
Plan of correction
Administrator/Designee will ensure that Emergency Preparedness and Response Plan, documentation will contain the date of when the review was completed.
22VAC40-73-870-A
Based on observation during a tour of the building, the facility failed to ensure the interior of the building shall be maintained in good repair and kept clean.
Evidence
- The carpet in the hallway of the second floor contains multiple, large areas of staining throughout the middle of the carpet.
Plan of correction
Administrator/Designee will ensure the carpets will be maintained in good repair and kept clean.
22VAC40-73-640-A
Based on medication cart audit, facility medication management plan review, and staff interview, the facility failed to implement its medication management plan in regard to methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
- The facility’s medication management plan states that a narcotic log is completed by off-going and on-coming RMAs/LPN and a signature is required by both RMAs/LPN per shift.
- During on-site inspection on 10/21/2025, at approximately 10:27AM, the licensing inspector (LI) observed that the Narcotic Count/Key Transfer Sheet for the medication cart assigned to staff person 3 contained the signature of staff person 3 as the outgoing 7AM-3PM medication staff person for 10/21/2025. Staff person 3 revealed to the LI that they should not have signed the Narcotic Count/Key Transfer Sheet as the outgoing medication staff person as they have not yet counted with the oncoming medication staff person and staff person 3 informed the LI the facility’s policy/procedure is for staff to not sign the sheet until they have counted and confirmed all the narcotics are accounted for with another medication staff person.
Plan of correction
Administrator/Designee will ensure that the Narcotic Log is not signed before the count is completed with the on-coming staff person. Training was held with staff person 3 on 10/23/25.
June 25, 2025Inspection
Inspection dates
06/25/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES
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: 06/25/2025 8:53AM to 3:05PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.
If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview.
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area.
Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-90-40-B
Based on staff record review and staff interview, the facility failed to ensure the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee.
Evidence
- Staff person 1 was hired on 03/06/2025; however, the criminal record history report in the record for staff person 1 is dated 04/15/2025 which is greater than 30 days prior to the staff person’s 30th day of employment. Interview with staff person 2 confirmed this is accurate.
Plan of correction
22VAC40-90-40B
Administrator/designee will obtain a criminal record history on or prior to the 30th day of employment for employees.
Date of Correction: 6/26/2025
June 25, 2025Complaint survey
Inspection dates
06/25/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/25/2025 8:53AM to 3:05PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by VDSS Division of Licensing on 05/30/2025 regarding allegations in the area of: resident care and related services
Number of residents present at the facility at the beginning of the inspection: 95
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.
If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview.
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area.
Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-470-A
Based on resident record review and staff interview, the facility failed to ensure, either directly or indirectly, that the health care service needs of residents are met.
Evidence
- The record for resident 1 contains a clinician visit progress note, electronically signed and dated 12/10/2024, that the resident was seen by the physician on this date for edema of left hand. The record for the resident also contains a signed physician’s order, dated 12/10/2024, to please fit resident with compression glove of left hand.
- Staff person 2 revealed to the licensing inspector (LI) during an interview on 06/25/2025 that the resident was never fit for a compression glove nor did the resident ever have a compression glove.
Plan of correction
Administrator/designee will ensure the needs of the residents are met for health care services indirectly and directly.
Date of Correction: 6/26/2025
22VAC40-73-680-I
Based on resident record review and staff interview, the facility failed to ensure the medication administration record (MAR) included dates the medication is discontinued or changed.
Evidence
- Resident 1’s September 2024 MAR provided to the licensing inspector (LI) by staff person 1 during on-site inspection on 06/25/2025 contains a black, thick line crossing out the following medications: Prednisone 5MG tablet take 1.5 tablets = 7.5MG by mouth daily at 8:00AM and Lisinopril 10MG take 2 tablets = 20MG daily at 8:00AM Resident 1’s October and November 2024 MARs provided to the LI by staff person 1 during on-site inspection on 06/25/2025 contains a black, thick line crossing out the following medications: Lisinopril 10MG take 2 tablets = 20MG daily at 8:00AM, Hydroxyzine HCL 25MG take one tablet two times daily at 8:00AM and 8:00PM, and Acetaminophen 325MG take two tablets = 650MG every six hours at 12:00AM, 6:00AM, 12:00PM, and 6:00PM, Acetaminophen 325MG take two tablets = 650MG every four hours as needed, and Tramadol HCL 50MG take one tablet every four hours as needed.
- The LI was informed during the on-site inspection on 06/25/2025 that staff person 1 spoke with staff person 2 regarding the aforementioned medications that had been marked through and staff person 2 stated that the medications would have been marked through due to the medications having been discontinued. The September, October and November 2024 MARs do not contain information on the MARs that the aforementioned medications had been discontinued. Staff person 1 confirmed this is accurate.
Plan of correction
The administrator/designee will ensure documentation of discontinued medications are obtained.
Date of Correction: 6/26/2025
22VAC40-73-300-B
Based on resident record review and staff interview, the facility failed to ensure that a method of written communication shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by resident, including complaints and incidents or injuries related to physical or mental conditions, the record shall be kept of the written communication for at least the past two years, and the information shall be included in the records of the involved residents.
Evidence
- Documentation provided by staff person 1 via email on 06/26/2025 to the licensing inspector (LI) revealed that resident 1 was hospitalized from 10/28/2024 to 10/30/2024 due to an admission of encephalopathy, UTI, and AKI; however, facility staff progress notes provided to the LI during on-site inspection on 06/25/2025 did not contain documentation that the resident was hospitalized from 10/28/2024 to 10/30/2024. An interview with staff person 1 revealed to the LI that it was not included in the facility’s communication log.
- Facility staff notes contain documentation, dated 01/01/2025 at 6:31AM, that the resident has symptoms of the flu throwing up and loose stool. The record for resident 1 contains emergency department discharge instructions, dated 01/01/2025 at 12:18PM, that the resident was at the emergency department and was diagnosed with diarrhea and cognitive impairment. During on-site inspection, staff person 1 was unable to provide the LI anything from the facility’s written communication log that included information that the resident had been to the ER on 01/01/2025.
Plan of correction
Administrator/designee will ensure that documentation is updated in the written log pertaining to residents for communication between staff members.
Date of Correction: 6/26/2025
22VAC40-73-680-D
Based on resident record review, the facility failed to ensure medications were administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
- Staff person 1 emailed the licensing inspector (LI) hospital discharge documentation for resident 1 from a hospitalization the resident had from 10/28/2024 to 10/30/2024 which was electronically signed by a physician on 10/30/2024 at 10:02AM. The hospital discharge documentation contained a statement that the resident was to continue medications as before this hospital stay and the only additional medication is ciprofloxacin 500MG twice daily for 5 days to treat urinary tract infection. The resident’s October and November 2024 medication administration records (MARs) do not contain documentation that the resident was administered ciprofloxacin 500MG twice daily for 5 days. Interview with staff person 1 confirmed this is accurate.
- The record for resident 1 contained a signed physician’s order, dated 09/27/2024, to change Prednisone to 5MG by mouth every day, (the resident was previously prescribed Prednisone 7.5MG by mouth daily), however, the October 2024 MAR for the resident contains documentation that the resident was administered Prednisone 7.5MG daily at 8:00AM instead of 5MG daily at 8:00AM.
- The record for resident 1 contained a signed physician’s order, dated 09/19/2024, to discontinue Lisinopril daily; however, the resident’s October 2024 MAR contains staff initials for administering Lisinopril 20MG at 8:00AM from 10/01/2024 to 10/16/2024 and 10/18/2024 to 10/28/2024 even though the medication had been discontinued.
Plan of correction
Administrator/ designee will ensure medications are administered according to the prescriber’s orders following the instructions and documented accurately. Administrator/designee will review MARs/prescribing orders for consistency and accuracy.
Date of Correction: 7/1/2025
22VAC40-73-650-F
Based on resident record review and staff interview, the facility failed to ensure whenever a resident is admitted to a hospital for treatment of any condition, the facility shall obtain new orders for all medications and treatments prior to or at the time of the resident’s return to the facility and the facility shall ensure that the primary physician is aware of all medication orders and has documented any contact with the physician regarding the new orders.
Evidence
- Staff person 1 emailed the licensing inspector (LI) hospital discharge documentation for resident 1 from a hospitalization the resident had from 10/28/2024 to 10/30/2024. The documentation contains a statement that the resident is to continue medications as before this hospital stay and the only additional medication is ciprofloxacin 500MG twice a day for 5 days to treat urinary tract infection.
- Staff person 1 revealed that the record for resident 1 does not contain any documentation that the resident’s physician was contacted about the order for ciprofloxacin or the resident’s hospitalization.
Plan of correction
The facility will obtain new orders for medications and treatments following hospitalization and make the primary physician aware of medication orders. Contact between facility and physician will be documented.
Date of Correction: 7/1/2025
22VAC40-73-560-E
Based on resident record review and staff interview, the facility failed to ensure all resident records shall be kept current and retained at the facility.
Evidence
- The record for resident 1 contained a signed physician’s order, dated 09/10/2024, for home health speech therapy – 1x a week for 1 week, 2x a week for 2 weeks and 1x a week for 6 weeks. The licensing inspector (LI) asked to review the speech therapy notes for the resident. The LI received the home health notes via email from staff person 1; however, staff person 1 stated the facility had to reach out to obtain the notes as they were not available in the facility to send to the LI.
- The record for resident 1 contained an orders reconciliation report from the hospital that was signed by a hospital physician on 10/30/2024. The LI asked staff person 1 if these signed physician’s orders were from a hospitalization as the record didn’t contain that information. Staff person 1 gave additional notes to the LI for review about the hospitalization; however, staff person 1 stated she had to reach out to the hospital and obtain the notes as they were not available in the facility during the on-site inspection.
- The record for resident 1 contained a staff progress note, dated 01/25/2025 at 2:40PM, that the resident was complaining of neck pain, went to give PRN and help adjust and resident started crying to the touch of her neck, called responsible party and an agreement to send resident to ER was reached. During on-site inspection on 06/25/2025, the record for resident 1 did not contain any documentation about the ER visit. Staff person 1 gave documentation to the LI regarding the ER visit; however, staff person 1 stated she had to reach out to the hospital and obtain the notes as they were not available in the facility during the on-site inspection.
Plan of correction
Administrator/ designee will ensure residents records are kept current and retained at the facility.
Date of Correction: 6/26/2025
April 22, 2025Complaint survey
Inspection dates
04/22/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/22/2025 8:50AM to 3:30PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by VDSS Division of Licensing on 03/03/2025 regarding allegations in the area of: resident care and related services
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 3
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.
If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview.
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area.
Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.stokes@dss.virginia.gov
Violations
22VAC40-73-650-B
Based on resident record review, the facility failed to ensure that physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications, and dietary supplements shall include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often the medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug.
Evidence
- The record for resident 1 contains a signed physician’s order, dated 06/07/2024, with the following statement: “Patient may have nutritional supplement of choice in his room and eat/drink as he desires”.
- The aforementioned physician’s order does not include the route, dosage, how often the resident may have the supplement, nor does the order identify the diagnosis, condition, or specific indications for administration of the nutritional supplement.
Plan of correction
Obtain order to include route, dosage, how often the resident may have the supplement, diagnosis, condition, and specific indication for administration.
The facility will follow physician’s or other prescribed orders of medication administration.
Date of correction: 4/22/25
22VAC40-73-680-D
Based on resident record review, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber's instructions.
Evidence
- The record for resident 1 contains a signed as needed (PRN) physician’s order, dated 06/27/2024, for Glucose 4 G tab chew 1 tablet by mouth as needed if blood sugar (BS) less than 70 – recheck BS after 30 minutes, repeat dose until BS greater than 90, if BS less than 70 after 2 doses or unresponsive or lethargic, notify medical doctor. The December 2024 MAR for resident 1 contains documentation that on 12/06/2024 at 8:00AM the resident’s BS was 68, on 12/10/2024 at 4:28PM the resident’s BS was 59, on 12/11/2024 at 8:00AM the resident’s BS was 60, on 12/11/2024 at 11:30AM the resident’s BS was 68, and on 12/23/2024 at 8:08AM the resident’s BS was 55; however, there is no documentation on the December 2024 MAR of staff following the aforementioned as needed physician’s order for when the resident’s BS is less than 70.
- The record for resident 1 contains a signed physician’s order, dated 01/03/2025, for Glucose 4 G tab chew 4 tablets by mouth once as needed for blood sugar (BS) less than 80 for hypoglycemia. The January 2025 MAR for resident 1 contains documentation that on 01/05/2025 at 11:45AM the resident’s BS was 16, on 01/09/2025 at 9:23AM the resident’s BS was 79, on 01/10/2025 at 3:58PM the resident’s BS was 76, on 01/12/2025 at 11:44AM the resident’s BS was 50, on 01/13/2025 at 11:27AM the resident’s BS was 53, on 01/16/2025 at 11:36AM the resident’s BS was 53 and on 01/20/2025 at 12:48PM the resident’s BS was 53; however, there is no documentation on the January 2025 MAR of staff following the aforementioned as needed physician’s order for when the resident’s BS is less than 80.
Plan of correction
Administrator conducted an inservice for Registered Medication Aides to follow physicians orders according to medication administration and document in the resident’s records.
Date of Corrections: 4/30/25
22VAC40-73-680-I
Based on resident record review and staff interview, the facility failed to ensure the medication administration record (MAR) shall include any medication errors or omissions.
Evidence
- Interview with staff person 2 revealed that if a medication staff person has circled their initials on a MAR, that indicates that the medication was not administered.
- The July 2024 paper MAR for resident 1 contains numerous days that the resident’s prescribed/scheduled 8:00PM Toujeo Solostar insulin, 8:00PM Breztri Aeroshphere Inhaler and 8:00PM Flonase nasal spray contained a circle by medication administration staff as not being administered. Staff person 1 informed the licensing inspector (LI) that they were unable to locate the back of the July 2024 paper MAR to show why the resident was not administered these medications.
- The September 2024 paper MAR for resident 1 contains numerous days that the resident’s prescribed/scheduled 8:00AM Polyethylene Glycol and 8:00PM Flonase nasal spray contained a circle by medication administration staff as not being administered; however, there were 18 instances of medication administration staff persons circling their initials for Polyethylene Glycol and 12 instances of medication administration staff persons circling their initials for Flonase nasal spray; however, the MAR did not contain documentation as to why the medications were not administered on these dates.
- The record for resident 1 contains a signed physician’s order, dated 06/07/2024, to give sliding scale insulin of Humalog with meals or Ensure but no more frequently than every 4 hours: blood sugar (BS) 200-250 – administer 2 units of Humalog; BS 251-300 – administer 4 units of Humalog; 301-350 – administer 6 units of Humalog; BS 351-400 – administer 8 units of Humalog; and BS above 400 – administer 10 units of Humalog; resident may keep glucometer at bedside and staff are to record readings, amount, and site. The resident’s December 2024 MAR indicates that on 12/01/2024 at 8:00AM the resident’s BS was 208 and at 11:30AM the resident’s BS was 209; however, the MAR does not contain documentation of how many units of the medication was administered to the resident.
- The record for resident 1 contains a signed physician’s order, dated 02/19/2025, to give sliding scale insulin of Lispro before meals and at bedtime per the following sliding scale order: if BS less than 60, call MD; if BS 60 to 150, give 0 units; if BS 151 to 199, give 1 unit; if BS 200 to 249, give 2 units; if BS 250 to 299, give 3 units; if BS 300 to 349, give 4 units; if BS 350 to 400, give 5 units; if BS is greater than 400, call medical doctor. The resident’s February 2025 MAR contains documentation that the resident’s BS on 02/27/2025 at 7:33AM was 349 and at 11:55AM was 359 and on 02/28/2025 at 10:59AM was 242; however, the MAR does not contain documentation of how many units of insulin was administered to the resident. The resident’s March 2025 MAR contains numerous dates that the resident was to be administered insulin based on the sliding scale insulin order; however, the MAR does not contain documentation of how many units of insulin was administered to the resident.
- The record for resident 1 contains a signed physician’s order, dated 04/02/2025, for insulin Lispro check BS before meals and at bedtime and inject per sliding scale insulin: 60-199 = 0 (zero) units; 200-299 = 4 units; 300-400 = 8 units and to notify medical doctor if BS is less than 60 or greater than 400. The resident’s April 2025 MAR contains numerous dates that the resident was to be administered insulin based on the sliding scale insulin order; however, the MAR does not contain documentation of how many units of insulin was administered to the resident.
Plan of correction
Adminstrator conducted an inservice for Registered Medication Aides to document in the resident’s MAR how many units of insulin is being adminstered following the sliding scale insulin order and medication administration documentation shall include any omissions and reasons for not administering medications. Inservice included notifying the physician of abnormal blood sugar parameter per physician orders.
Date of Correction: 4/30/25
22VAC40-73-580-F
Based on resident record review and staff interview, the facility failed to ensure to implement interventions as soon as a nutritional problem is suspected, and the interventions shall include weighing residents at least monthly to determine whether the resident has significant weight loss (i.e., 5.0% weight loss in one month, 7.5% in three months, or 10% in six months); and notifying the attending physician if a significant weight loss is identified in any resident who is not on a physician-approved weight reduction program and obtaining, documenting, and following the physician’s instructions regarding nutritional care.
Evidence
- The record for resident 1 contains a nutrition progress note, dated 09/11/2024, that based on Collateral 2’s review of resident 1’s record on this date, Collateral 2 recommended that the facility make the resident’s provider aware of the resident’s recent significant weight loss.
- During on-site inspection on 04/22/2025, the licensing inspector (LI) was provided a monthly weight log by staff persons 1 and 2 that contains documentation that the resident’s weight was 233.8lbs in October 2024, 234.2lbs in November 2024, and 234lbs in December 2024. The LI was also provided with a document printed from the facility’s electronic medical system that contains documentation that the resident’s weight was 198.6lbs on 01/08/2025 at 2:16PM, 199lbs on 02/25/2025 at 11:12AM, 197lbs on 03/04/2025 at 12:38PM, 196.6lbs on 03/12/2025 at 9:37AM, 195lbs on 03/19/2025 at 2:12PM, 195.2lbs on 03/20/2025 at 9:25AM, and 195.2lbs on 03/31/2025 at 11:45AM. A discharge summary in the record for resident 1 from Collateral 1, dated 02/24/2025 at 9:11AM, contains documentation that the resident’s weight was 197.6lbs.
- The resident’s documented weight of 234lbs in December 2024 and 198.6lbs on 01/08/2025 is greater than 5% weight loss in one month; however, the record for resident 1 contains a document, “MD WEIGHT NOTIFICATION FORM”, that the resident’s primary physician was not notified of the resident’s weight loss until 03/25/2025. Interview with staff person 2 confirmed this is accurate.
Plan of correction
Administration/ designee will obtain weights per physician order and any significant weight changes will be reported to the physician.
Date of correction: 5/22/25
22VAC40-73-680-E
Based on resident record review and staff interview, the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented and the documentation shall be maintained in the resident’s record.
Evidence
- The record for resident 1 contains a signed physician’s order, dated 06/07/2024, to give sliding scale insulin of Humalog with meals or Ensure but no more frequently than every 4 hours: blood sugar (BS) 200-250 – administer 2 units of Humalog; BS 251-300 – administer 4 units of Humalog; 301-350 – administer 6 units of Humalog; BS 351-400 – administer 8 units of Humalog; and BS above 400 – administer 10 units of Humalog; resident may keep glucometer at bedside and staff are to record readings, amount, and site. The resident’s July 2024 and August 2024 paper medication administration records (MARs) contains numerous dates/times that the resident’s blood sugar (BS) was not recorded on the MARs. The resident’s September 2024 paper MAR and October 2024 paper MAR do not contain any documentation of BS readings during these two months. Interview with staff persons 1 and 2 confirmed this is accurate and could not locate any BS readings for the resident elsewhere. 2. The record for resident 1 contains a signed physician’s order, dated 06/27/2024, to check and record blood sugar (BS) as needed for hyperglycemia/hypoglycemia – if less than 70 or greater than 400 notify medical doctor, if unresponsive call 911; see glucose order for BS less than 70. Interview with staff person 1 during on-site inspection on 04/22/2025 revealed to the licensing inspector (LI) that this as needed order would apply to every BS check/reading that is done on the resident including daily scheduled BS checks. The resident’s December 2024 MAR contains documentation that on 12/06/2024 at 8:00AM the resident’s BS was 68, on 12/10/2024 at 4:28PM the resident’s BS was 59, on 12/11/2024 at 8:00AM the resident’s BS was 60, on 12/11/2024 at 11:30AM the resident’s BS was 68, and on 12/23/2024 at 8:08AM the resident’s BS was 55 and the resident’s January 2024 MAR contains documentation that on 01/12/2025 at 11:44AM the resident’s BS was 50, on 01/13/2025 at 11:27AM the resident’s BS was 53, on 01/17/2025 at 11:09AM the resident’s BS was 63 and on 01/20/2025 at 12:48PM the resident’s BS was 53; however, staff persons 1 and 2 were unable to provide documentation of staff following the aforementioned physician’s order of contacting the resident’s physician when the resident’s BS is less than 70. The January 2025 MAR for the resident contains documentation that on 01/05/2025 at 11:45AM the resident’s BS was 16 and that the resident’s primary physician’s office was contacted; however, the record for the resident does not contain documentation of what the resident’s physician’s response was regarding the resident’s BS. The January 2025 MAR for the resident contains documentation that on 01/16/2025 at 11:36AM the resident’s BS was 53. Staff person 2 provided to the LI a fax communication sheet, dated 01/6/2025, that states “please review blood sugars and sign attached order” in which staff person 2 stated was for the resident’s low BS reading on this date; however, staff person 2 was unable to provide documentation of what the resident’s physician reply back was regarding the fax communication.
- The record for resident 1 contains a signed physician’s order, dated 10/09/2024, to check the resident’s blood pressure (BP) obtain and record BP 2 times daily for monitoring. The document, “Blood Pressure Sheet”, for October 2024 for the resident contains multiple dates that the resident’s BP was not recorded at least two times daily. (additional documentation would not fit on this notice)
Plan of correction
Administrator conducted an inservice for Registered Medication Aides to notify the physician and document the response of the physician referring to blood sugar in the resident’s record/MAR. Blood pressure to be documented according to orders in the resident’s record/MAR.
Date of correction: 4/30/25
22VAC40-73-460-F
Based on resident record review and staff interview, the facility failed to ensure to notify the next of kin, legal representative, designated contact person, or, if applicable, any responsible social agency of any incident of a resident falling, whether or not it results in injury, this notification shall occur as soon as possible but no later than 24 hours from the time of initial discovery or knowledge of the incident and the resident’s record shall include documentation of the notification, including date, time, caller, and person or agency notified.
Evidence
- The record for resident 1 contains a resident incident report, dated 07/29/2924 at 7:30PM, that the resident had informed staff that he was attempting to put Ensures in his refrigerator, Ensure fell on the floor, he bent over to pick it up and fell and the incident report contains documentation that the resident was assessed for injuries and was lifted from the floor to his dining room chair.
- The record for resident 1 does not contain documentation of notification to the resident’s next of kin, legal representative, or designated contact person.
- Interview on 04/22/205 with staff persons 1 and 2 confirmed this is accurate.
Plan of correction
Administrator conducted an inservice for direct care staff for the facility will notify next of kin/ legal representative of any incident of falls within 24 hours and document in resident’s record.
Date of Correction: 4/30/25
April 22, 2025Inspection
Inspection dates
04/22/2025
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: 04/22/2025 8:50AM to 9:30AM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 2
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.stokes@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
February 28, 2025Inspection
Inspection dates
02/28/2025
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: 02/28/2025 9:20AM to 10:05AM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
Number of residents present at the facility at the beginning of the inspection: 33 assisted living level, 73 independent living level
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Observations by licensing inspector: medication carts
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.
If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview.
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area.
Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.stokes@dss.virginia.gov
Violations
22VAC40-73-660-B
Based on observation during a tour of the facility, resident interview, resident record review and staff interview, the facility failed to ensure a resident may be permitted to keep his own medication in an out-of-sight place in his room if the UAI (uniform assessment instrument) has indicated that the resident is capable of self-administering medication.
Evidence
- The UAI for resident 1, dated 06/28/2024 indicates that the resident requires her medications to be administered/monitored by lay person – registered medication aide and/or nurse.
- During on-site inspection on 02/28/2025, the licensing inspector (LI) and staff person 1 observed a container of Hydrocortisone cream and two bottles of dry-eye eye drops sitting on the side table beside the recliner resident 1 was sitting in. During an interview with resident 1, the resident informed the LI and staff person 1 that she uses the Hydrocortisone cream daily on her legs due to her legs being itchy and dry and she uses the eye drops once a day.
- The record for resident 1 does not contain an order that the resident can have and self-administer the medication. Interview with staff person 1 confirmed this is accurate.
Plan of correction
Corrective Actions:
1. Immediate Actions Taken:
Assessment Review: We will conduct an immediate review of the Uniform Assessment Instruments (UAls) for all residents who are permitted to self administer medications to ensure that only those who are appropriately assessed are st-0ringmedications in their rooms.
Securing Medication: Any medication stored inappropriately or accessed by other residents will be removed form the resident's room, and proper secure storage methods will be implemented immediately.
2. Resident Education and Training:
Staff Education: All staff will receive additional training on the facility's policy regarding medication storage, ensuring that they understand how to monitor and enforce medication security. This will include steps to identify potential risks and how to address them promptly.
3. Medication Storage Plan:
Inspection Process: Staff will conduct routine checks to verify that residents who store medications in their rooms are in compliance with the facility's policies.
Timeline for Corrective Actions:
• Resident and Staff Training (Completed within 60 days):
• Conduct a training session on medication storage practices and self administration protocols for both residents and staff.
• Ongoing Monitoring (Initiated immediately and ongoing):
• Daily monitoring of medication storage.
• Monthly audits to ensure continued compliance.
1. Resident and Family Communication:
The facility will communicate the importance of proper medication storage to residents and their families, highlighting their role in keeping medications secure and the facility's responsibility to ensure their safety.
December 17, 2024Inspection
Inspection dates
12/17/2024
Areas reviewed
22VAC40-73 PERSONNEL
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: 12/17/2024 8:40AM to 10:31AM
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: 35 assisted living level of care, 69 independent living
Number of resident records reviewed: 0
Number of staff records reviewed: 12
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 4
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.
If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview.
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area.
Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.stokes@dss.virginia.gov
Violations
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
- During an on-site inspection conducted on 12/17/2024, 2 licensing inspector’s (LI’s) noted documentation of a training conducted by staff person 2 in the records for staff persons 3, 4, and 5. The certificates have documentation that the employees “Has successfully completed the 40-hour training approved by the Virginia Department of Social Services” and “The curriculum is based on section 22VAC40-73-200-C”.
- In an interview with 2 licensing inspectors (LI’s) and staff person 2 conducted on-site on 12/17/2024, staff person 2 expressed that they had not been on-site in the facility to conduct the 40-hour direct care staff training for these individuals but was aware that their typed name and/or signature was on the certificates for these employees.
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 person3. Staff person 4 has a certificate on file noting completion of the Virginia Personal Care Aide 40- Hour Training through another entity dated completion 06/26/2023, and staff person 5 was terminated due to Violation of code 22VAC 90-40D.
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
- During on-site inspection conducted on 12/17/2024, staff persons 3, 4, and 5 hired during staff person 1’s time as the facility administrator were noted to be on the facility daily assignment sheets from 11/03/2024 through 12/15/2024 working independently as direct care staff. In an interview conducted on-site on 12/17/2024 with 2 licensing inspectors (LI’s) and staff persons 1 and 2, staff persons 1 and 2 confirmed that the direct care training that staff persons 3, 4 and 5 received did not follow the department approved curriculum as it was not provided by a registered nurse or licensed practical nurse, which does not meet the requirements of 22VAC40-73-200-C.7. The records for staff persons 8, 9 and 10 were noted to be on the facility daily assignment sheets from 11/03/2024 to 12/15/2024 working independently as direct care staff but the records for these staff do not have documentation of a certificate for completion of a direct care staff training. Interview with staff persons 1 and 2 confirmed this is accurate.
- During on-site inspections conducted on 12/17/2024, 6 employees hired between 07/03/2024 to 11/22/2024 who have not yet met required training as outlined in standard 22VAC40-73-200-C-1 through 7 were noted to be on the facility daily assignment sheets working independently as direct care staff. Staff person 1 confirmed that the facility does not have a written plan of supervision for these employees until their training is completed.
Plan of correction
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. Staff person 8 has a certificate on file from another entity noting the completion of the program on 08/08/2022, staff person 9 completed the 40-hour Direct Care Course at Runk and Pratt School of Instruction on 01/17/2025, and staff person 10 was terminated.
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
- The records for staff persons 3, 4, 5, 8, 9 and 10 do 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 daily assignment logs from 11/03/2024 to 12/16/2024 contains documentation of these staff persons working independently in a direct care staff capacity.
- In an interview with 2 licensing inspectors (LI’s) and staff persons 1 and 2 on 12/17/2024, staff persons 1 and 2 confirmed that these individuals are working without supervision as direct care aides. Staff persons 1 and 2 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.
22VAC40-90-40-B
Based on staff record review and staff interview, the facility failed to ensure the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee.
Evidence
- The record for staff person 8, date of hire 11/12/2024, did not contain a criminal history record report.
- During on-site inspection on 12/17/2024, interview with staff person 7 revealed she would reach out to corporate to obtain the criminal history record report for staff person 8.
- As of 02/12/2025, documentation of a criminal history record report has not been provided for staff person 8.
Plan of correction
Administrator or Designee will ensure that staff criminal history record is on file for each employee prior to the 30th day of employment. This staff member has a Criminal History Record Name Search Request on file dated 11/12/2024, a Virginia State Police Detail Report Received 12-06-2024 showing “Searching” as the status and a Commonwealth of Virginia Department of State Police Civil and Applicant Records Exchange with a received date at 12/10/2024. This had not been filed at the time of this inspection but had been reviewed.
22VAC40-73-120-A
Based on staff record review and staff interview, the facility failed to ensure the orientation and training required in 22VAC40-73-120-B and 22VAC40-73-120-C occurred within the first seven working days of employment.
Evidence
- On 12/17/2024, the day of on-site inspection, the facility daily assignment logs have documentation that staff person 6, date of hire 09/11/2024 and start date 09/23/2024, and staff person 9, date of hire 11/04/2024 and start date 11/07/2024, worked more than seven days between 11/03/2024 to 12/16/2024.
- The records for staff persons 6 and 9 did not contain documentation that these staff persons completed the required orientation and training within the first seven working days of employment. In an interview with 2 licensing inspectors (LIs) and staff person 7 on the day of on-site inspection, staff person 7 acknowledged that there was no documentation of any orientation in the records for staff persons 6 and 9 and was unable to confirm if an orientation and training had been completed for these two staff persons.
Plan of correction
Administrator or Designee will ensure that staff orientation and initial training has been completed within seven working days of employment. Additionally, documentation of this training will be kept in the employee’s file.
22VAC40-90-40-D
Based on staff record review and document review, the facility failed to ensure that an employee has not been convicted of any of the barrier crimes when a criminal history record was requested.
Evidence
- The document, “Barrier Crimes for Licensed Assisted Living Facilities and Adult Day Care Programs” dated October 2023, states that an assisted living facility cannot hire anyone who has a conviction for an offense in clause (i) of the barrier crime definition in 19.2-392.02 of the Code of Virginia.
- The record for staff person 5, date of hire 07/03/2024, contained a Virginia criminal record, that staff person 5 was found guilty of a felony barrier crime on 06/25/2010 that is listed on the document “Barrier Crimes for Licensed Assisted Living Facilities and Adult Day Care Programs”.
Plan of correction
Administrator or Designee will ensure that staff employed by the licensed assisted living have met the requirements for the barrier crimes outlined in the Virginia Code. Staff person 5 was terminated.