Inspection Reports for
Runk & Pratt of Forest
208 Gristmill Drive, FOREST, VA, 24551
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
17 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
87% worse than Virginia average
Virginia average: 9.1 deficiencies/year
Deficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
58 residents
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 21, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-11-05 regarding allegations in the area of resident care and related services.
Complaint Details
Complaint related to resident care and related services; the allegations were not substantiated.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection summary will be posted to the VDSS website within 5 business days of receipt.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 0
Staff interviews conducted: 1
Inspection Report
Monitoring
Deficiencies: 0
Date: Nov 21, 2025
Visit Reason
The inspection was a monitoring visit conducted on November 21, 2025, following a self-reported incident received by VDSS regarding allegations in the area of resident care and related services.
Findings
The investigation did not support the self-report of non-compliance with standards or law. The inspection findings will be posted publicly and an exit meeting was planned to review the findings.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 0
Staff interviews conducted: 1
Inspection Report
Monitoring
Deficiencies: 0
Date: Nov 21, 2025
Visit Reason
The inspection was a monitoring visit conducted to review resident care and related services at the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. The inspection summary will be posted publicly within five business days.
Inspection Report
Monitoring
Census: 58
Deficiencies: 0
Date: Oct 6, 2025
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. No deficiencies were cited.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 0
Staff interviews conducted: 1
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 0
Date: Sep 3, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-08-22 regarding allegations in the area of resident care and related services.
Complaint Details
Complaint investigation related to allegations in resident care and related services; the complaint was not substantiated.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Report Facts
Number of residents present: 54
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: 1
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 0
Date: Sep 3, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-08-22 regarding allegations in the area of resident care and related services.
Complaint Details
Complaint investigation related to allegations in resident care and related services; the complaint was not substantiated.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly within 5 business days of receipt.
Report Facts
Number of residents present: 54
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: 2
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 0
Date: Sep 3, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2025-08-22 regarding allegations in the area of resident care and related services.
Complaint Details
Complaint related to resident care and related services; the allegations were not substantiated based on the investigation.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and an exit meeting was planned to review the findings.
Report Facts
Residents present: 54
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 0
Staff interviews conducted: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Named as the current inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 0
Date: Sep 3, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-08-22 regarding allegations in the area of resident care and related services.
Complaint Details
Complaint related to allegations in resident care and related services; investigation found no substantiation of non-compliance.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection summary will be posted to the VDSS website within 5 business days of receipt.
Report Facts
Number of residents present: 54
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: 1
Inspection Report
Monitoring
Census: 55
Deficiencies: 1
Date: Aug 21, 2025
Visit Reason
The inspection was a monitoring visit conducted on August 21, 2025, to review resident care and related services following a self-report received regarding allegations in this area.
Findings
The investigation did not support the self-report of non-compliance; however, violations unrelated to the self-report were identified, specifically the facility failed to ensure the uniform assessment instrument (UAI) was completed as required for private pay individuals.
Deficiencies (1)
The facility failed to ensure that the uniform assessment instrument (UAI) was completed as required by 22VAC30-110 for private pay individuals, specifically lacking documentation of resident 1's abusive/aggressive/disruptive behaviors toward other residents.
Report Facts
Number of residents present: 55
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Named as the current inspector conducting the inspection |
| Staff person 1 | Agreed that the resident's UAI should contain documentation about abusive/aggressive/disruptive behaviors |
Inspection Report
Monitoring
Census: 55
Deficiencies: 0
Date: Aug 21, 2025
Visit Reason
The inspection was a monitoring visit conducted on August 21, 2025, following self-reported incidents received by VDSS regarding allegations in resident care and related services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. No deficiencies were explicitly stated in the report.
Report Facts
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Date: Aug 21, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-07-08 regarding allegations in the area of resident care and related services.
Complaint Details
Complaint related to resident care and related services; allegations were not substantiated based on the investigation.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly within 5 business days.
Report Facts
Residents present: 55
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 0
Staff interviews conducted: 1
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Date: Aug 21, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a self-reported incident received by VDSS Division of Licensing on 2025-08-11 regarding allegations in the area of resident care and related services.
Complaint Details
The complaint was related to resident care and related services. The investigation did not substantiate the allegations of non-compliance.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted to the VDSS website within 5 business days of receipt.
Report Facts
Number of residents present: 55
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: 1
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: Aug 21, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 08/21/2025 regarding allegations related to resident care and related services.
Complaint Details
The complaint was substantiated based on staff interviews and observations showing that some staff, specifically staff person 2, could not communicate effectively with residents, using a phone translation app and failing to respond to questions or comprehend resident service plans.
Findings
The investigation found that the facility failed to ensure that care and services were provided by staff able to communicate effectively with residents in a language they understand, as evidenced by staff person 2's inability to communicate or comprehend resident needs and documents.
Deficiencies (1)
Facility failed to ensure staff could communicate with residents in a language they understand to ensure accurate exchange of information.
Report Facts
Number of residents present: 55
Number of staff records reviewed: 1
Number of interviews conducted with staff: 5
Date of correction: 2026
Inspection Report
Renewal
Census: 55
Deficiencies: 6
Date: Aug 21, 2025
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for the facility's license renewal.
Findings
The inspection found multiple violations including failure to update individualized service plans, incomplete annual review of resident rights with staff, medication management deficiencies, medication administration errors, cleanliness issues with air vents, and incomplete criminal background checks for staff.
Deficiencies (6)
Failed to ensure individualized service plans (ISPs) were reviewed and updated at least annually and as needed for significant changes.
Failed to ensure annual review of resident rights and responsibilities was completed with all staff.
Failed to implement medication management plan to ensure accurate counts of controlled substances during staff changes.
Failed to administer medications in accordance with physician's orders, resulting in over-administration of eye drops.
Failed to maintain the interior of all buildings in good repair and kept clean; air vents noted with dust and dark substance.
Failed to obtain criminal history record report on or prior to the 30th day of employment for a staff member.
Report Facts
Number of residents present: 55
Number of resident records reviewed: 11
Number of staff records reviewed: 3
Number of staff interviews conducted: 4
Medication doses administered: 35
Medication doses ordered: 28
Inspection Report
Monitoring
Census: 56
Deficiencies: 0
Date: May 15, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care standards and additional requirements for adults with serious cognitive impairments.
Findings
The inspection found no violations with applicable standards or laws. The licensing inspector completed a tour of the physical plant and reviewed resident records without identifying any deficiencies.
Report Facts
Resident records reviewed: 4
Staff records reviewed: 0
Interviews conducted with residents: 0
Interviews conducted with staff: 1
Inspection Report
Monitoring
Census: 56
Deficiencies: 0
Date: May 15, 2025
Visit Reason
The inspection was a monitoring visit conducted to review personnel and resident care related services at the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. The inspection summary will be posted publicly within five business days.
Inspection Report
Monitoring
Census: 56
Deficiencies: 0
Date: May 15, 2025
Visit Reason
The inspection was a monitoring visit conducted to review personnel standards at the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. The inspection summary will be posted publicly within five business days.
Report Facts
Number of resident records reviewed: 0
Number of staff records reviewed: 14
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Inspection Report
Monitoring
Census: 52
Deficiencies: 0
Date: Jan 8, 2025
Visit Reason
The inspection was a monitoring visit conducted to review resident care and related services, including investigation of self-reported incidents received by VDSS Division of Licensing regarding allegations in resident care.
Findings
The evidence gathered during the investigation did not support the self-reports of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Report Facts
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: 2
Inspection Report
Monitoring
Census: 52
Deficiencies: 4
Date: Jan 8, 2025
Visit Reason
The inspection was a monitoring visit to assess compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found multiple violations including unsecured hazardous materials accessible to residents, failure to prepare and serve prescribed diets according to physician orders, lack of a current diet manual for staff, and incomplete documentation of medical procedures and treatments as ordered by physicians.
Deficiencies (4)
Facility failed to ensure ordinary materials or objects harmful to residents were inaccessible; door to room B7 was unlocked with power tools and nails accessible.
Facility failed to prepare and serve prescribed no concentrated sweets diet according to physician orders; chocolate chip cookies served to residents on such diet.
Facility failed to maintain a current diet manual containing acceptable practices and standards for nutrition readily available to food preparation personnel.
Facility failed to ensure medical procedures or treatments ordered by a physician were provided and documented according to instructions; blood pressure readings were not consistently documented for resident 3.
Report Facts
Number of residents present: 52
Number of resident records reviewed: 7
Number of staff records reviewed: 4
Number of staff interviews conducted: 3
Carbohydrates per cookie: 26
Total sugars per cookie: 16
Added sugars per cookie: 15
Inspection Report
Monitoring
Census: 52
Deficiencies: 3
Date: Jan 8, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with personnel standards, including staff training and supervision.
Findings
The inspection found non-compliance with personnel standards, specifically failures in administration oversight, incomplete direct care staff training, and lack of a written supervision plan for staff not yet fully trained.
Deficiencies (3)
Facility administrator failed to be responsible for general administration and management regarding training and supervision of staff.
Facility failed to ensure employees working as direct care staff completed a department approved 40-hour direct care staff training program within the first two months of employment.
Facility failed to develop and implement a written plan for supervision of direct care staff who have not yet met training/qualification requirements.
Report Facts
Number of residents present: 52
Number of staff records reviewed: 20
Number of interviews conducted with staff: 2
Number of employees working without required training: 17
40-hour Direct Care Course completion dates: 4
Training completion deadline: May 15, 2025
Inspection Report
Monitoring
Census: 52
Deficiencies: 1
Date: Oct 29, 2024
Visit Reason
The inspection was a monitoring visit conducted on October 29, 2024 and January 8, 2025, following a self-reported incident regarding allegations in personnel and resident care and related services.
Findings
The investigation supported the self-report of non-compliance related to staff communication abilities, including an incident where a staff member purposely scratched a resident and was unable to understand English, impacting care delivery. Violations were issued and a plan of correction was required to ensure proper communication methods.
Deficiencies (1)
Facility failed to ensure care and services were provided by staff able to communicate with residents in a language they understand, resulting in an incident involving resident and staff injury.
Report Facts
Number of residents present: 52
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: 3
Inspection Report
Monitoring
Census: 56
Deficiencies: 1
Date: Oct 22, 2024
Visit Reason
The inspection was a monitoring visit conducted on October 22, 2024, following a self-reported incident received on October 12, 2024, regarding allegations in resident care and additional requirements for facilities caring for adults with serious cognitive impairments.
Findings
The investigation supported the self-report of non-compliance related to resident safety, specifically that the facility failed to ensure harmful materials were inaccessible to a resident with serious cognitive impairment. Violations were issued and a plan of correction was submitted involving installation of locks to secure razors.
Deficiencies (1)
The facility failed to ensure that ordinary materials or objects that may be harmful to a resident were inaccessible except under staff supervision, as evidenced by a resident obtaining a razor and injuring himself.
Report Facts
Number of residents present: 56
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
Inspection Report
Monitoring
Census: 57
Deficiencies: 1
Date: Oct 7, 2024
Visit Reason
The inspection was a monitoring visit conducted on October 7 and 8, 2024, following a self-reported incident received on September 11, 2024, regarding allegations in personnel and resident care areas.
Findings
The investigation did not support the self-report of non-compliance; however, a violation unrelated to the self-report was identified concerning failure to report a major incident within 24 hours as required by standard 22VAC40-73-70-B.
Deficiencies (1)
Facility failed to ensure a report to the regional licensing office within 24 hours of any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident, including omission of resident names involved in the incident.
Report Facts
Number of residents present: 57
Number of resident records reviewed: 0
Number of staff records reviewed: 1
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Inspection Report
Monitoring
Census: 57
Deficiencies: 16
Date: Oct 7, 2024
Visit Reason
The inspection was a monitoring visit conducted on October 7 and 8, 2024, to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection found multiple violations of state regulations including staffing shortages during night hours, failure to submit timely incident reports, incomplete staff orientation and training, inadequate documentation of falls and individualized service plans, improper diet and medication administration, and deficiencies in staff recordkeeping such as missing sworn statements and criminal history reports.
Deficiencies (16)
Staffing levels during night hours were insufficient with only 5 direct care staff on duty when at least 6 were required.
Failure to submit a written report of incidents to the regional licensing office within seven days.
Orientation and training for new staff did not occur within the first seven working days of employment.
Verification that staff received a copy of their current job description was not maintained.
Staff did not submit results of tuberculosis risk assessment prior to starting work.
Aggressive behavior training for staff lacked a demonstration component.
Facility failed to post the name of the current on-site person in charge in a conspicuous place.
Lack of documentation analyzing falls and interventions to prevent subsequent falls for residents.
Individualized service plans were not signed and dated by the licensee, administrator, or designee.
Diets prescribed by physicians were not prepared and served according to orders.
Medications were not administered according to physician or prescriber instructions.
Medical procedures or treatments ordered by a physician were not consistently documented or provided as ordered.
The most recent inspection findings were not posted on the premises.
Sworn statements or affirmations were not completed for all applicants for employment.
Criminal history record reports were not obtained on or prior to the 30th day of employment for some employees.
Criminal history record reports older than 90 days prior to employment were accepted.
Report Facts
Number of residents present: 57
Number of resident records reviewed: 8
Number of staff records reviewed: 6
Number of interviews with residents/family: 2
Number of interviews with staff: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current inspector conducting the monitoring inspection |
| Staff person 1 | Named in multiple findings including staffing levels, incident reporting, medication administration, and training | |
| Staff person 2 | Observed administering medication incorrectly | |
| Staff person 3 | Named in findings related to job description, aggressive behavior training, and staff records | |
| Staff person 4 | Named in findings related to job description | |
| Staff person 5 | Named in findings related to criminal history record reports | |
| Staff person 6 | Named in findings related to medication administration and criminal history record reports | |
| Staff person 7 | Named in findings related to orientation, tuberculosis risk assessment, sworn statements, and criminal history record reports | |
| Staff person 8 | Named in findings related to sworn statements and criminal history record reports |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 29, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-02-21 regarding allegations related to resident care and related services at the facility.
Complaint Details
The complaint was partially substantiated. Evidence showed that staff administered morphine prescribed for one resident to another resident due to lack of available medication, violating proper medication administration protocols.
Findings
The investigation found that some, but not all, of the allegations were substantiated, specifically non-compliance in resident care and related services. A violation was issued related to medication management.
Deficiencies (1)
The facility failed to ensure that medications ordered for PRN administration were available, properly labeled for the specific resident, and properly stored at the facility.
Report Facts
Doses of morphine administered from another resident's medication: 27
Dates of physician orders: Physician orders dated 2024-01-08 and 2024-02-17 for morphine administration for resident 1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person 1 was interviewed and confirmed administering morphine prescribed for resident 2 to resident 1. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 19, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-11-15 regarding allegations in the areas of personnel and resident care and related services.
Complaint Details
Complaint related to personnel and resident care and related services; allegations were not substantiated.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. An exit meeting was planned to review the inspection findings.
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 3
Date: Nov 9, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-10-30 regarding personnel and additional requirements for facilities that care for adults with serious cognitive impairments.
Complaint Details
The complaint was substantiated as the evidence gathered supported the allegations of non-compliance with standards related to personnel and care for adults with serious cognitive impairments.
Findings
The investigation found multiple violations related to staffing levels during night hours, failure to provide required cognitive impairment training within four months of employment, and failure to ensure first aid certification within 60 days of employment for direct care staff.
Deficiencies (3)
Facility failed to ensure during night hours that when more than 40 residents are present, at least four direct care staff members plus at least one more direct care staff member for every additional 10 residents shall be awake and on duty at all times in each special care unit.
Facility failed to ensure that within four months of the starting date of employment, direct care staff shall attend at least 10 hours of training in cognitive impairment.
Facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days of employment.
Report Facts
Census count: 63
Direct care staff required: 7
Direct care staff present: 6
Direct care staff present: 5
Inspection Report
Renewal
Census: 61
Deficiencies: 3
Date: Aug 29, 2023
Visit Reason
The inspection was a renewal inspection conducted to evaluate the facility's compliance with applicable standards and laws as part of the license renewal process.
Findings
The inspection found non-compliance with applicable standards and laws, including deficiencies related to water temperature maintenance, documentation of safety checks for residents unable to use signaling devices, and expired items in the first aid kit.
Deficiencies (3)
Facility failed to ensure that hot water at taps available to residents is maintained within a range of 105 to 120 degrees Fahrenheit.
Facility failed to ensure documentation of daily rounds was completed for residents with an inability to use a signaling device.
Facility failed to ensure that items in the first aid kit with expiration dates did not have dates that have already passed.
Report Facts
Number of residents present: 61
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of interviews conducted with staff: 4
Water temperatures recorded: 101.8
Water temperatures recorded: 99.7
Water temperatures recorded: 102
Water temperatures recorded: 102.3
Expiration date of ointment: 2019
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 1, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-06-20 regarding allegations related to additional requirements for facilities that care for adults with serious cognitive impairments.
Complaint Details
Complaint was received on 2023-06-20 regarding additional requirements for facilities that care for adults with serious cognitive impairments. The evidence gathered did not support the allegations.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection findings will be publicly disclosed and posted on the VDSS website.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Named as the current inspector conducting the complaint investigation. |
Inspection Report
Monitoring
Deficiencies: 1
Date: Mar 2, 2023
Visit Reason
The inspection was conducted as a monitoring visit in conjunction with local adult protective services following a self-reported incident regarding allegations in resident care and additional requirements for adults with serious cognitive impairments.
Findings
The inspection found non-compliance with applicable standards related to medication storage. Specifically, schedule II drugs and other drugs subject to abuse were not kept in a separate locked storage compartment, allowing unauthorized access to morphine.
Deficiencies (1)
Facility failed to ensure schedule II drugs and other drugs subject to abuse were kept in a separate locked storage compartment.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 10, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2022-11-08 regarding allegations related to personnel, staffing and supervision, and resident care and related services.
Complaint Details
Complaint was received on 2022-11-08 regarding personnel, staffing & supervision, and resident care. The evidence gathered did not support the allegations of non-compliance.
Findings
The investigation did not substantiate the complaint allegations; however, a violation unrelated to the complaint was identified regarding failure to report a major incident affecting a resident within 24 hours to the regional licensing office.
Deficiencies (1)
Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected a resident.
Report Facts
Date of incident: Nov 6, 2022
Inspection duration: 40
Plan of correction timeframe: 5
Plan of correction timeframe: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 21, 2022
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2022-09-15 regarding allegations in the areas of personnel and resident care and related services.
Complaint Details
Complaint was received by VDSS Division of Licensing on 2022-09-15 regarding allegations in personnel and resident care and related services. The evidence gathered did not support the allegations of non-compliance with standards or law.
Findings
The investigation did not support the allegations of non-compliance related to the complaint; however, a violation unrelated to the complaint was identified regarding a direct care staff member not receiving first aid certification within 60 days of employment.
Deficiencies (1)
Facility failed to ensure a direct care staff member received first aid certification within 60 days of employment.
Report Facts
Date of hire for staff: Mar 8, 2022
Date of certification: May 24, 2022
Days allowed for certification: 60
Inspection Report
Renewal
Census: 55
Deficiencies: 4
Date: Sep 21, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and laws.
Findings
The inspection found non-compliance with several standards related to medication management, medication administration, and facility maintenance. Violations were documented and a plan of correction was requested to address these issues.
Deficiencies (4)
Failed to implement medication management plan ensuring accurate counts of controlled substances during staff changes.
Failed to ensure medications remained in pharmacy issued container until administered to residents.
Failed to ensure medications were administered according to physician's instructions.
Failed to ensure the interior of the building was maintained in good repair.
Report Facts
Number of residents present: 55
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of resident interviews: 3
Number of staff interviews: 3
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 17, 2022
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2022-06-28 regarding allegations related to resident care and medication management.
Complaint Details
The complaint was substantiated; evidence supported the allegation of non-compliance with medication management standards.
Findings
The investigation found non-compliance with medication management standards, specifically failures in implementing the facility's medication management plan, including improper disposal and documentation of controlled medications.
Deficiencies (1)
Facility failed to ensure implementation of their medication management plan, including proper disposal and documentation of controlled medications.
Report Facts
Dates of medication returns and destructions: Medication returns and destructions documented on various dates including 09/18/2021, 10/01/2021, 01/08/2022, 01/11/2022, 01/16/2022, 01/04/2022, and 01/14/2022.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 21, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2022-05-13 regarding allegations related to additional requirements for facilities that care for adults with serious cognitive impairments.
Complaint Details
Complaint related to additional requirements for facilities that care for adults with serious cognitive impairments; no violations found.
Findings
The evidence gathered during the inspection determined no violations with applicable standards or law. The inspection summary will be posted to the VDSS website within five business days of receipt.
Inspection Report
Monitoring
Census: 62
Deficiencies: 1
Date: Jun 21, 2022
Visit Reason
This inspection was conducted as the first of two inspections for the facility's provisional license. High risk violations cited at the facility's renewal inspection on 2022-03-22 were reviewed.
Findings
The inspection determined non-compliance with applicable standards or law, specifically a failure to ensure that prior to admitting a resident with serious cognitive impairment due to dementia, the licensee or designee determined whether placement in the special care unit was appropriate. Documentation was incomplete as the approval letter lacked a date.
Deficiencies (1)
Failed to ensure prior to admitting a resident with serious cognitive impairment due to dementia that placement in the special care unit was appropriate; approval document lacked a date.
Report Facts
Number of residents present: 62
Inspection Report
Monitoring
Deficiencies: 1
Date: Apr 11, 2022
Visit Reason
An unannounced monitoring inspection was conducted to follow up on a facility reported incident on 03/12/2022 involving an altercation between a resident and a visitor.
Findings
The facility failed to submit a written report of the incident to the regional licensing office within seven days as required. The inspector reviewed training records, video footage, and documentation related to the incident.
Deficiencies (1)
Facility failed to submit a written report of an incident to the regional licensing office within seven days from the date of the incident that negatively affected or threatened the life, health, safety, or welfare of any resident, signed and dated by the administrator including all required information.
Report Facts
Days to submit incident report: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Conducted the inspection |
| Staff 1 | Sent initial email about incident and confirmed failure to submit written report |
Inspection Report
Renewal
Census: 56
Deficiencies: 10
Date: Mar 22, 2022
Visit Reason
An unannounced renewal study was conducted on 03/22/2022 to assess compliance with the Standards for Assisted Living Facilities, including a tour, medication pass observation, record reviews, and staff/resident interviews.
Findings
Multiple deficiencies were identified including failure to secure harmful materials from residents with cognitive impairments, incomplete resident disclosure statements, incomplete individualized service plans, medication management plan implementation failures, medication administration errors, unsecured cleaning supplies, and facility maintenance issues.
Deficiencies (10)
Facility failed to ensure harmful materials were inaccessible to residents with serious cognitive impairment.
Disclosure statements for residents did not include all required components and were not on department-approved forms.
Individualized service plans (ISPs) lacked required components including service provider details and accurate supervision needs.
Medication management plan was not fully implemented; narcotic counts lacked required signatures.
Medications, dietary supplements, diets, or treatments were changed without valid physician orders or were administered outside prescribed times.
Medications were found outside pharmacy-issued containers and some were pre-poured contrary to standards.
Medication administration records (MARs) did not document all administered medications.
Cleaning supplies were stored in an unlocked laundry room accessible to residents.
Facility interior and exterior were not maintained in good repair and cleanliness; stained carpets, brown liquid stains, and scuff marks were observed.
Nutritional supplements were unlabeled and accessible to residents.
Report Facts
Residents in care: 56
Medication administration time deviation: 1
Medication count discrepancies: 1
Medication administration record omissions: 3
Inspection Report
Monitoring
Census: 63
Deficiencies: 1
Date: Jan 26, 2022
Visit Reason
A focused, non-mandated, monitoring inspection regarding an intensive plan of correction (IPOC) was conducted to review staffing levels for facilities caring for adults with serious cognitive impairments.
Findings
The inspection found that the facility failed to ensure adequate night shift staffing levels according to regulations, with fewer direct care staff on duty than required based on census during the night hours from 01/09/2022 through 01/25/2022. The previous violation was cited as a repeat violation.
Deficiencies (1)
Facility failed to ensure during night hours that when more than 40 residents are present, at least four direct care staff members plus at least one more direct care staff member for every additional 10 residents, or portion thereof, shall be awake and on duty at all times in each special care unit.
Report Facts
Census: 63
Census: 62
Census: 61
Required direct care staff: 7
Actual direct care staff: 2
Actual direct care staff: 3
Actual direct care staff: 4
Actual direct care staff: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Named as current inspector conducting the inspection |
| staff 1 | Provided census report and staff schedule, and confirmed accuracy of staffing information |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 14, 2021
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to a complaint received on 12/14/2021 regarding allegations in resident care and related services about medications and pest control in buildings and grounds.
Complaint Details
The complaint contained allegations regarding medications and pest control. After reviewing documentation, resident records, and interviewing staff, the complaint was found to be not valid with no violations.
Findings
The investigation did not support the allegations, and the complaint was determined to be not valid. No violations resulted from this complaint investigation.
Inspection Report
Monitoring
Census: 66
Deficiencies: 3
Date: Nov 10, 2021
Visit Reason
The licensing inspector initiated a monitoring inspection following a self-report of a resident elopement. The inspection included a telephone interview and an on-site visit to review documentation and observe resident rooms.
Findings
The facility failed to ensure protective devices on bedroom and common area windows to prevent residents from opening windows wide enough to crawl through. Additionally, the Individualized Service Plan (ISP) for a resident did not accurately reflect the resident's non-ambulatory status and flight risk, and supervision of the resident's care and activities was inadequate.
Deficiencies (3)
Failure to ensure protective devices on bedroom and common area windows to prevent residents from opening windows wide enough to crawl through.
Failure to ensure that the Individualized Service Plan (ISP) addressed all identified needs of the resident.
Failure to ensure supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering from the premises.
Report Facts
Residents in care: 66
Inspection dates: Inspection conducted on 2021-10-19 (telephone) and 2021-11-10 (on-site)
Temperature range: Temperature between 79 and 84 degrees Fahrenheit during resident elopement on 2021-10-15
Inspection Report
Monitoring
Census: 66
Deficiencies: 1
Date: Oct 19, 2021
Visit Reason
A focused, non-mandated monitoring inspection was conducted to determine correction and compliance with a previously cited B2 violation related to staffing requirements during night hours for facilities caring for adults with serious cognitive impairments.
Findings
The facility was found to have repeated violations for failing to ensure adequate direct care staff were awake and on duty during night hours when the census exceeded 40 residents. Staffing schedules showed fewer staff than required on multiple dates between 10/04/2021 and 10/18/2021.
Deficiencies (1)
Facility failed to ensure during night hours that when more than 40 residents are present, at least four direct care staff members plus at least one more direct care staff member for every additional 10 residents, or portion thereof, shall be awake and on duty at all times in each special care unit.
Report Facts
Census: 63
Census: 64
Census: 65
Census: 66
Direct care staff required: 7
Direct care staff on duty: 5
Direct care staff on duty: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Inspector | Named as current inspector conducting the inspection |
| staff 1 | Provided census report and staff schedule; interviewed to confirm staffing information |
Inspection Report
Monitoring
Census: 61
Deficiencies: 2
Date: Aug 27, 2021
Visit Reason
A focused, non-mandated monitoring inspection was conducted to determine correction and compliance with B2 violations cited during a previous focused, non-mandated monitoring inspection in the areas of resident care and additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The facility failed to ensure adequate direct care staffing during night hours based on census and failed to ensure medications were not discontinued without a valid physician order. One violation was cited as a repeat.
Deficiencies (2)
Facility failed to ensure during night hours that when more than 40 residents are present, at least four direct care staff members plus at least one more direct care staff member for every additional 10 residents, or portion thereof, shall be awake and on duty at all times in each special care unit.
Facility failed to ensure that medications were not discontinued without a valid order from a physician or other prescriber.
Report Facts
Census: 60
Census: 61
Direct care staff required: 6
Direct care staff required: 7
Direct care staff worked: 4
Direct care staff worked: 6
Inspection Report
Monitoring
Census: 54
Deficiencies: 3
Date: Jun 15, 2021
Visit Reason
A focused monitoring inspection was conducted on 06/15/2021 to determine correction and compliance with B2 violations cited during the facility's renewal inspection and a recent complaint inspection in the areas of personnel, resident care, and additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The facility failed to ensure adequate night staffing levels based on census, failed to have physician's or prescriber's oral orders reviewed and signed within 14 days, and failed to administer medication according to physician or prescriber instructions.
Deficiencies (3)
Facility failed to ensure during night hours that when more than 40 residents are present, at least four direct care staff members plus at least one more direct care staff member for every additional 10 residents shall be awake and on duty at all times in each special care unit.
Facility failed to have a physician's or other prescriber's oral orders reviewed and signed by a physician or other prescriber within 14 days.
Facility failed to administer medication in accordance with the physician's or other prescriber's instructions.
Report Facts
Census: 54
Direct care staff required: 6
Direct care staff scheduled: 5
Days for physician order signature: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Inspector | Current inspector conducting the inspection |
| Staff 1 | Interviewed staff who provided information on census, staffing, and medication orders | |
| Staff 2 | Staff educated on following physician orders related to medication administration deficiency |
Inspection Report
Renewal
Census: 50
Deficiencies: 5
Date: Feb 24, 2021
Visit Reason
A renewal inspection was initiated to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple non-compliances including failure to document written justification for admitting residents with serious cognitive impairment, lack of annual aggressive behavior training for staff, incomplete individualized service plans, failure to review residents' rights annually, and medication administration errors.
Deficiencies (5)
Failed to ensure written determination and justification prior to admitting residents with serious cognitive impairment.
Failed to ensure annual aggressive behavior training for staff.
Failed to ensure individualized service plan included written description of services to address identified needs.
Failed to ensure annual review and written acknowledgment of residents' rights and responsibilities.
Failed to ensure medications were administered according to physician's orders.
Report Facts
Resident records reviewed: 3
Staff records reviewed: 3
Fire drills reviewed: 3
Medication administration errors: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Inspector | Conducted the inspection |
| Dr. Betz | Physician who issued medication orders for resident 3 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 16, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding resident care and reporting at the facility. The investigation was conducted remotely due to a state of emergency health pandemic.
Complaint Details
Complaint related: Yes. A complaint was received regarding allegations in resident care and reporting. The investigation did not substantiate the allegations of non-compliance.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. However, two violations were noted related to failure to update fall risk rating after a fall and failure to ensure the individualized service plan included descriptions of identified needs based on current physician's orders.
Deficiencies (2)
Facility failed to ensure that the fall risk rating shall be reviewed and updated after a fall.
Facility failed to ensure that the comprehensive individualized service plan includes a description of identified needs and date identified based upon current physician's orders.
Report Facts
Dates referenced: 2
Dates referenced: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Inspector | Current inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 5, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding personnel, staffing and supervision, resident care and related services, buildings and grounds, and resident accommodations.
Complaint Details
A complaint was received regarding personnel, staffing and supervision, resident care and related services, buildings and grounds, and resident accommodations. The evidence did not support these allegations except for a staffing level violation cited in a separate complaint dated 01/21/2021.
Findings
The investigation did not support the allegations of non-compliance with standards or law; however, one staffing level violation cited in a separate complaint was noted.
Deficiencies (1)
Standard 1130 C (staffing levels) violation cited in a separate complaint.
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 6
Date: Jan 21, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding personnel and resident care and related services. The investigation was conducted remotely due to a state of emergency health pandemic.
Complaint Details
The complaint investigation was substantiated for one allegation of non-compliance related to staffing and resident care. Violations were issued for multiple standards including staffing levels, work schedule maintenance, medication orders, and staff training.
Findings
The investigation supported one allegation of non-compliance and identified multiple violations related to staffing levels during day and night shifts, failure to maintain accurate written work schedules, and deficiencies in medication orders and staff training on oxygen equipment.
Deficiencies (6)
Facility failed to ensure adequate direct care staff awake and on duty during day hours based on census.
Facility failed to ensure adequate direct care staff awake and on duty during night hours based on census.
Facility failed to maintain a written work schedule including names, job classifications, person in charge, and noted absences or substitutions.
Facility failed to ensure medication, dietary supplement, diet, medical procedure or treatment was not stopped or changed without a valid physician order.
Facility failed to ensure a valid physician's order for oxygen contained all required components.
Facility failed to ensure all direct care staff assisting residents with oxygen supplies had training or instruction in use and maintenance of resident-specific equipment.
Report Facts
Census counts: 62
Direct care staff required: 7
Direct care staff on duty: 3
Dates of staffing deficiencies: 6
Date of scheduled in-service training: 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Inspector | Conducted the complaint investigation |
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