VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Spring Oak Assisted Living at Petersburg
590 Flank Road
Petersburg, VA 23805
(804) 861-6977

Current Inspector: Tamara Watkins (804) 662-7422

Inspection Date: Dec. 2, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 12/2//2021 and concluded on 3/8/2021. A complaint was received by the department regarding allegations in the areas of Personnel; Staffing and Supervision; Resident Care and Related Services; and Building and Grounds. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. A virtual inspection and interview was also, completed. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-100-A
Complaint related:	No
Description:	Based on a virtual tour of the building, the facility failed to implement the infection control program that is consistent with the federal Centers for Disease Control and Prevention (CDC) guidelines. Evidence: 1. During the virtual tour on 2/9/2021, the staff member working in the kitchen was observed wearing her mask below her chin. 2. The facility Policy and Procedure titled, ?Infection Control: Guidance for Management of (COVID) as set forth by Virginia Code 22VAC40-73-100? with a ?Last Revision? date of 11/15/2020 received from the facility via e-mail on 1/6/2021 notes on page 5 under ?Personal Protective Equipment (PPE) & Supplies? the following: a. ?Masks: In accordance with recently revised CDC Guidelines, masks are to be worn by all members of staff within the community at all times while in the building.?
Plan of Correction:	1. Dietary staff were immediately educated on mask mandate which requires them to be worn at all times and must properly cover both their nose and mouth. 2. All residents have the potential to be affected if facility staff fail to properly wear masks at all times. 3. Facility administrator or designee will educate all staff on CDC mask mandate requiring mouth and nose to be covered. 4. Facility administrator or designee will round daily x 5 per week x2 months to ensure all staff are following the required mask protocol. 5. Expected date of compliance: April 9, 2021.
Standard #:	22VAC40-73-190-A
Complaint related:	No
Description:	Based on a review of documentation and an interview with staff, the facility failed to ensure that when the administrator, the designated assistant, or the manager is not awake and on duty on the premises, that there was a designated direct care staff member in charge of the premises. Evidence: 1. The Daily Assignment sheet submitted upon request for 11/26/2020 noted Staff #1 was scheduled to work from 7-12, and Staff #3 from 3-11. 2. The Timecard Report noted that on 11/26/2020, Staff #1 clocked out at 12:00pm and Staff #3 clocked in at 6:56pm. 3. During a virtual interview on 2/9/2021, the administrator stated that Staff #7 was supposed to work from 12:00pm - 4:00pm because staff was working in four hour blocks for the Thanksgiving Holiday. The administrator stated that the staff member scheduled as the Medication Tech is the person in charge. The administrator stated that Staff #3 was running late. 4. The Timecard Reported noted that no Medication Technician had clocked in between the hours of 12:00pm and 6:55pm. During a virtual interview on 2/9/2021, the administrator stated that ?there was no Medication Tech during that time so that is completely accurate and there was no one in charge.?
Plan of Correction:	1. Administrator was notified and immediately implemented emergency phone tree protocols to obtain coverage. 2. All residents have the potential to be affected if facility staff fail to properly designate coverage of person in charge when the administrator is not on the premises. 3. All staff will be educated on ensuring that there is, at all times, a designated person in charge prior to them leaving the center to ensure coverage when the Administrator is not on the premises. 4. Administrator or designee will conduct audits twice weekly x2 months to ensure that there are no further incidents of failure to designate person in charge when the Administrator is not on the premises. 5. Expected Date of Completion April 9, 2021
Standard #:	22VAC40-73-290-A
Complaint related:	No
Description:	Based on a review of staff schedules and an interview with staff, the facility failed to maintain a written work schedule that includes the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time and any absences, substitutions, or other changes noted on the schedule. Evidence: 1. The complainant stated that, while on site on 11/26/2020, no staff members could tell her who was in charge. 2. Staff #1: a. The Monthly Work Schedule document for November 2020 submitted by the facility noted staff #1 as a Medication Technician (MT) on 11/26/2020 for the 7am-3pm shift. The Daily Assignment document dated 11/26/2020 submitted by the facility noted staff #1 was scheduled to work 7-12. The Time Card Report noted staff #1 clocked in at 6:50 am and clocked out at 12:00 pm. 3. Staff #3: a. The Monthly Work Schedule document for November 2020 submitted by the facility did not note that staff #3 was scheduled to work on 11/26/2020. The Daily Assignment document dated 11/26/2020 noted staff #3 as ?Med Tech/Charge? for 3-11. The Timecard Report noted that staff #3 clocked in at 06:56pm and clocked out at 11:00pm. 4. Staff #7: a. The Monthly Work Schedule document for November 2020 submitted by the facility noted that staff #7 was scheduled to work on 11/26/2020 from 11pm - 7am. The Daily Assignment document dated 11/26/2020 noted staff #7 as working 11-7. b. The Timecard Report shows that staff #7 did not clock-in on 11/26/2020. c. During a virtual interview with the administrator on 2/9/2021, the administrator stated that staff #7 was supposed to work from 12n - 4pm on 11/26/2020 but did not come in to work. 5. The facility did not maintain the November 2020 Monthly Staff Schedule to reflect any absences, substitutions on the schedule. 6. The November 2020 Monthly Staff Schedule did not contain job classifications for: a. 7am - 3pm for staff #2, 3, 8, 9, or 10. b. 3pm - 11pm for staff #3, 7-8 and 10-16. c 11pm - 7am for staff #2, 7, 9, 12, 17, and 19.
Plan of Correction:	1. Facility Scheduler educated on regulation 22VAC40-73-(4)-290-A to ensure that she directs staff to notate any changes to the master schedule as they occur. 2. All residents have the potential to be affected if facility staff fail to maintain written work schedule notating any absences, substitutions, or other changes. 3. Facility staff will be educated on notating changes to the schedule as they occur and communicating those changes to the Administrator or designee. 4. Facility administrator or designee will monitor schedule and meet with scheduler twice weekly x2 months to ensure that all changes to the schedule are communicated and noted appropriately. 5. Expected date of compliance: April 9, 2021
Standard #:	22VAC40-73-290-B
Complaint related:	No
Description:	Based on a virtual tour of the building and an interview with a staff member, the facility failed to implement a procedure to ensure that it posted the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. The complainant stated that she never knows who is in charge. 2. During a virtual inspection on 2/9/2021, the administrator was asked to virtually show where the designated staff person in charge is posted. The administrator showed a medication room posting on a wall. Clarification was requested regarding where in the common area it was posted for visitors. The administrator stated that location was normally at the entrance to the facility in a frame but that it was not being posted currently since no visitors were coming in the facility due to the pandemic. 3. It was requested that the area be shown during the virtual inspection. It was virtually shown that there was a picture frame in the lobby by the entrance on a table with a stop sign and a statement regarding visitation.
Plan of Correction:	1. Facility Scheduler educated on regulation 22VAC40-73-(4)-290-B to ensure that person in charge form is posted daily in a conspicuous place open to the public. 2. All residents have the potential to be affected if facility staff fail to post the person in charge notification daily in a conspicuous place open to the public as stated in 22VAC40-73(4)-290-B. 3. All Facility staff will be educated on ensuring the person in charge form is posted daily in a conspicuous place open to the public as stated in 22VAC40-73-(4)-290-B. 4. Facility administrator or designee will inspect 3 times weekly x2 months to ensure that the person in charge form is posted in a conspicuous place open to the public. 5. Expected date of completion: April 9, 2021.
Standard #:	22VAC40-73-300-B
Complaint related:	No
Description:	Based on a review of facility documents the facility failed to provide a method of communication on all shifts that keeps direct care staff informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical and mental conditions. Evidence: Daily shift communication forms were reviewed for the month of November, 2020. The events of 11/26/2021 regarding medication omissions for all residents affected including resident #1 were not noted. The administrator reported "there are only about six of us so we make sure we tell each other" about any significant events.
Plan of Correction:	1. Facility staff were immediately educated on the use of their communication log to ensure shift to shift events, complaints, incidents and injuries related to physical and mental conditions. 2. All residents have the potential to be affected if facility staff fail to document events, incidents, complaints, and injuries related to residents physical and mental conditions. 3. Facility Administrator/DON or designee will educate all staff on the use of communication logs to document events, complaints, incidents, and injuries related to residents physical and mental conditions. 4. Facility administrator or designee will audit communication logs 5 times weekly x2 months to ensure staff document all events, complaints, incidents, and injuries related to a residents physical and mental condition. 5. Expected date of compliance: April 9, 2021.
Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on a review of the Medication Administration Services document in the Policy and Procedure Manual, the facility failed to ensure the written plan for medication management was kept current and included all of the components required by the standard. Evidence: 1. The Medication Management Plan submitted for review via email on December 17, 2020 was not updated to reflect the new electronic Medication Administration Record (e-MAR) system that the staff began using in November 2020 and was not updated to include all of the components required by the standard. 2. The Medication Administration Services document does not address the following: a. Methods to ensure an understanding of the responsibilities associated with medication management. b. Standard operating procedures including the facility?s standard dosing schedule and any general restrictions specific to the facility. c. Methods to prevent the use of outdated, damaged, or contaminated medications. d. Methods to ensure that each resident?s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed doses. e. Methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order. f. Methods for monitoring medication administration and the effective use of the MARs for documentation, methods to ensure that MARs are maintained as part of the resident?s record. g. Methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes, methods to ensure that staff who are responsible for administering medications meet the qualification requirements of 22 VAC 40-73-670. h. Methods to ensure that staff who are responsible for administering medications are adequately supervised, including periodic direct observation of medication administration. i. Methods to ensure that residents do not receive medications or dietary supplements to which they have known allergies. j. Methods to ensure that staff who are responsible for administering medications are trained on the facility?s medication management plan. k. Procedures for internal monitoring of the facility?s conformance to the medication management plan.
Plan of Correction:	1. Pharmacy was contacted to provide us with a new Medication Administration Policy to include our new electronic MAR and all components required by this standard. New policy received 3/15/2021. 2. All residents have the potential to be affected if facility staff fail to ensure the written plan for Medication Administration/Management is kept current and includes all components required by standard 22 VAC40-73-(6)-640-A. 3. DON or designee will educate Medication Aides on the 22VAC40-73-(6)-640 standard requirements and the new Medication Administration Administration Policy that surrounds our new electronic MAR system. 4. DON or designee will educate Medication Aides on the Medication Administration Policy annually and within 90 days of hire to ensure compliance. 5. Expected Date of Completion; April 9, 2021.
Standard #:	22VAC40-73-680-C
Complaint related:	No
Description:	Based on a review of the Med Variance report, the facility failed to ensure that medications were administered not earlier than one hour before and not later than one hour after the facility?s standard dosing schedule, except for those drugs that are ordered for specific times. Evidence: A complaint was received on 12/02/2020 stating the resident did not receive her insulin injections on time. Residents #1-#23: 1. Upon review of the Med Variance Report, approximately 413 prescribed medications were administered more than one hour after scheduled administration time on November 1, 3, 5- 8, 13-15, 17-19, 2020. 2. Late administration times ranged from approximately three minutes to approximately two hours and six minutes. 3. Diagnosis for medications administered late include, but are not limited to pain, arthritis, hypertension, diabetes mellitus, blood pressure, anticoagulation, COPD, seizure disorder, mood disorder, thyroid, GERD, A-Fib, and dementia with behavioral disturbance. 4. Staff #1 documented ?First time user,? First time training,? ?First time training,? ?First Training Time,? ?First Time Training,? ?First time training,? ?First time training,? or ?First time training? under ?Notes? as indicated on the Med Variance report for November 1 - 30, 2020. Residents #3, 5 - 7, 9 - 19, 21, and 22: 1. Approximately 76 prescribed medication doses that were administered more than one hour prior to scheduled administration time on November 1,2,7,12,15,18, 2020. 2. Late administration times ranged from approximately one minute to approximately 48 minutes. 3. Diagnosis for medications administered late include, but not limited to, supplement, hypertension, rib cage pain, hyperlipidemia, cholesterol, Afib, diabetes mellitus, thyroid, bladder, allergies, seizures, memory, abdominal cramping, dementia, pain, OA pain, SPP, prophylaxis, Parkinson?s Disease, dry eyes, depression, mood disorder, back pain, and COPD. 4. Staff #1 documented ?First time training,? ?First time training,? ?First time user,? ?First day training,? ?First training,? or ?First day training? as indicated on the Med Variance report for November 1 - 30, 2020. Residents #6 and # 7: 1. Approximately seven prescribed medication doses were administered more than one hour after the scheduled administration time on November 3 and November 7, 2020. 2. Late administration times was approximately 14 minutes. 3. Diagnosis for medications administered late include, but not limited to, cholesterol, Afib, diabetes mellitus, HTN, and thyroid. 4. Staff #2 documented ?First time training,? and ?training? as indicated on the Med Variance report for November 1 - 30, 2020. Residents #2, 4 - 11, 13 - 15, 17 - 23: 1. Approximately 43 prescribed medication doses were administered more than one hour after the scheduled administration time on November 1 and 5, 2020. 2. Late administration times ranged from approximately 32 minutes to approximately seven hours and two minutes. 3. Diagnoses for medications administered late include, but not limited to, poor appetite, dementia with behaviors, dementia, HTN, hypertiglyceridemia, diabetes mellitus, allergies, prophylaxis, pain osteoarthritis, anxiety/agitation, seizure disorder, seizures, depression, OA pain, Parkinson?s Disease, bipolar, dry eyes, A-fib, CHF, high blood pressure disorder, mood swings, osteoarthritis pain, and psychosis. 4. Staff #4 documented ?new to system?, ?new to med pass?, ?staff training?, ?training? as indicated on the Med Variance report for November 1 - 30, 2020. **Due to the volume of information gathered during the inspection, a separate document has been created and is available upon request.***
Plan of Correction:	1. New administrator and Director of Nursing immediately set up training on electronic MAR system. Training completed on 12/10/2020. 2. All residents have the potential to be affected if facility staff fail to ensure medications are administered within one hour before/one hour after the ordered time as outlined in 22VAC40-73-(6)-680-C. 3. Medication Aides will be educated on use of the new MAR by DON or designee to ensure that they are aware of how to properly document and ensure medications are administered within the guidelines of facility dosing schedule. Administrator or designee will also evaluate the facility standard dosing schedule to ensure that medication administration times are optimal for all residents. 4. Don or designee will audit MAR's twice weekly x2 months to ensure that all medications are documented properly and administered within one hour before/one hour after time of order. 5. Expected Date of Completion: April 9, 2021.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on observation and the review of resident records, the facility failed to administer medications in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. Commonwealth of Virginia Board of Nursing Medication Aide Curriculum for Registered Medication Aides, Revised May 21, 2013 states: a. Chapter 5, Section 5.1 titled, ? 5.1 ?Describe Three Types of Forms Commonly Used to Document Medication Administration ? states, ?Documentation is an important part of medication management. It is frequently referred to as the ?6th Right? of medication administration. b. Section 5.3 titled ?Document Medication Administration on the Medication Administration Record states, ?All medications administered or omitted? under ?What to Document.? 2. The complainant stated that her parent did not receive any medications scheduled on 11/26/2020 between 2:00pm and 6:00pm. 3. Upon review of the Medication Administration Records (MAR), no documentation of medication administration or omission was completed on the November 2020 MAR for the following: a. Resident #1: All medication (two medications totaling six medication doses) scheduled for 2:00pm on 11/23-24 and 26, 2020, all 9:00pm doses (four medications totaling 16 medication doses) on 11/21-22, 11/ 24 and 11/30, 2020, and one medication (totaling one dose) scheduled for 4:00pm on 11/26/2020, all medications. Diagnoses for these medications include spasms, anxiety, allergies, and mood. All medications (eight medications totaling eight medication doses) scheduled for 11:00am on 12/9/2020, one medication totaling one medication dose scheduled for 11:00am on 12/25/2020, two medications totaling six medication doses scheduled for 2:00pm on 12/4, 12/9, and 12/25, 2020, all medications (four medications totaling 32 medication doses) scheduled for 9:00am on 12/5, 12/7, 12/10,12/14, 12/23-25, and 12/30, 2020. Diagnoses for these medications include mood, anxiety, allergies, spasm, depression, hypothyroidism, hypertension, and diabetes mellitus. b. Resident #4: One medication totaling one medication dose) scheduled for 8:00am on 12/13/2020, seven medications totaling seven medication doses scheduled for 9:00am on 12/13/2020. Diagnoses for these medications were not included on the MAR. c. Resident #7: All medications scheduled for November 26, 2020 at 5:00pm (two medications totaling two doses). Diagnoses for these medications include seizures and allergies. d. Resident #8: Five medications (totaling five medication doses) scheduled for 8:00am on 11/3/2020, two medications (totaling two medication doses) scheduled for 4:00pm on 11/2 and 11/26, 2020, one medication (totaling two medication doses) scheduled for 5:00pm scheduled for 11/2 and 11/26, one medication (totaling one medication dose) scheduled for 8:00pm on 11/24,2020, and one medication (totaling one medication dose) scheduled for 11/24/2020 at 7:00am. Diagnoses for these medications include hypertension, prophylaxis, MDD-R, GERD, and hypothyroidism. **Due to the volume of information gathered during the inspection, a separate document has been created and is available upon request.***
Plan of Correction:	1. Administrator made aware. Physician made aware. Medication Aide administered missed medications where appropriate. 2. All residents have the potential to be affected if facility staff fail to ensure medications are administered per physician's orders and instructions. 3. Medication Aides will be educated on medication administration by physician's order and/or instructions as well as standards of practice set forth in the Registered Medication Aide Curriculum. 4. DON or designee will observe medication pass weekly x2months to ensure clinical staff are administering medications per physician's order and instruction. 5. Expected Date of Completion: April 9, 2021.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on a review of the Medication Administration Records the facility failed to document on the resident MAR's the diagnosis, condition, or specific indications for administering the drug or supplement. Evidence: Following are a list of residents and the name of the drug prescribed that did not have diagnosis, condition, or specific indications for administering the drug or supplement on the November, 2020 MAR. Resident #14- Afluria Quad 2020-21 (3YR UP) PRN Resident # 3 - Bumetanide 1 mg tablet; Afluria Quad 2020-21 (3 YR UP) PRN Resident # 7 - Xarelto 20mg tablet; Afluria Quad 2020-21 (3 YR UP) PRN Resident # 8 - Afluria Quad 2020-21 (3 YR UP) PRN Resident # 1 - Clopidogrel 75mg tabs; Afluria Quad 2020-21 (3 YR UP) PRN; Loperamide HCL 2mg caps; Ondansetron 4mg ODT tab Resident #13 - Afluria Quad 2020-21 (3 YR UP) PRN; Cyclobenzaprine 10mg tab Resident #14 - Afluria Quad 20-21 QIV PFS PRN Resident #15 - Afluria Quad 2020-21 (3 YR UP) PRN Resident #16 - Calcitonin/SALM 200U SPY 3.7ml; Ferrous Sulf 325 mg tab; Furosemide 20mg tab; Prednisone 5mg tablet; Tamsulosin HCL 0.4mg capsule Resident #18 - Cefuroxime Axetil 250mg tab; Spironolactone 25mg tab Resident #19 - Baclofen 5mg tablet; Cetirizine 10mg; Clonidine 0.1mg tab; Escitalopram 10mg tab; Simvastatin 20mg tab Resident #22 - Docusate Sodium 100mg capsule; Afluria Quad 2020-21 (3 YR UP) PRN; Ondansetron 4mg ODT tab
Plan of Correction:	1. Facility Administrator/DON/Pharmacy consultant conducted 100% audit of all current residents to ensure that all orders include diagnosis, condition or specific indications for administering each drug or supplement on all orders entered onto the MAR. 2. All residents have the potential to be affected if facility staff fail to ensure all orders include diagnosis, condition, or specific indications for administering each drug or supplement on MAR's. 3. DON or designee will audit all new orders weekly x2 months to ensure that they include diagnosis, condition or specific indications for administering each drug or supplement on all orders entered on the MAR. 4. Facility administrator or designee will audit all MAR's monthly x2 months to ensure orders include diagnosis, condition or specific indications for administering each drug or supplement. 5. Expected date of compliance: April 9, 2021.
Standard #:	22VAC40-73-680-J
Complaint related:	No
Description:	Based on interviews with facility staff and a collateral interview, the facility failed to ensure that in the event of a medication error, the resident?s physician of record was notified as soon as possible and failed to ensure that actions taken were documented in the resident?s record. Evidence: 1. Section 5.4 titled ?Document Medication Errors? in the registered medication aide curriculum approved by the Virginia Board of Nursing (Revised May 21, 2013) states ?When a medication is not given as prescribed by the HCP, a medication error has occurred.? 2. A collateral telephone interview was held on 12/29/2020 with the prescriber who stated she was not notified by the facility that residents under care did not receive their prescribed medication scheduled between noon and 6:55pm on 11/26/2020. 3. The administrator, during a 2/9/2021 virtual interview, stated that she contacted the Nurse Practitioner herself on Thanksgiving Evening regarding Resident #1. 4. Upon request, the facility submitted all documentation completed in all resident records on 11/26/2020. Documentation for two residents were received. 5. During a 2/9/2021 virtual interview with the administrator, the administrator acknowledged that no documentation was completed for medication error for resident #1 on 11/26/2020.
Plan of Correction:	1. Physician notified of errors and all records have been noted accordingly. 2. All residents have the potential to be affected if facility staff fail to ensure medication aides properly document and follow medication error protocols. 3. Medication Aides will be educated on Medication Error protocols set forth in Spring Oak Assisted Living Policy and Procedure Manual. 4. DON or designee will audit MAR's and Medication variance reports twice weekly x2 months to ensure medication errors are properly documented and protocols are followed. 5. Expected Date of Completion April 9, 2021.
Standard #:	22VAC40-73-930-B
Complaint related:	No
Description:	Based on staff and resident interviews the facility failed to have a fully functional signaling device that allowed staff to determine the origin of the signal in a manner that was both audible and visible so that the staff was able to determine the origin of the signal. Evidence: On 11/28/21 resident #1 reported they attempted to use the pull the cord on the call bell signaling system with no staff response. The administrator reported that on that date the speaker system wasn?t working but is now repaired. The call bell lit up in a central location but there was no sound.
Plan of Correction:	1. Administrator contacted technician and had part ordered as soon as the annunciator was reported to be not audibly sounding. Residents were provided with hand bells. This has since been replaced and is fully functional. 2. All residents have the potential to be affected if facility signaling device is not fully functional. 3. All staff will be educated to ensure that they continue to report any such outage to management immediately. 4. Facility signaling device will be tested from randomly selected rooms weekly x2 months to ensure full functionality. 5. Expected date of compliance: April 9, 2021