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: May 25, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

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 monitoring inspection was initiated on 5/25/2021 and concluded on 6/25/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 27. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed (5) resident records, (2) staff records, staff schedules, medication administration records, individualized service plans, fire drills, health care oversight, etc.) submitted by the facility to ensure documentation was complete. This inspection also includes a follow up on previously cited high risk violations and an intensive plan of correction. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1130-A
Description:	Based on a review of staff schedules and accompanying documentation the facility failed to ensure that there were at least two direct care staff members awake on duty at all times in the special care unit who were responsible for the care and supervision of the residents. Evidence: At the time of the inspection there were (10) residents present in the memory care unit. The evidence reflects the dates and time the memory care unit was not staffed with two direct care staff members on the 7am -3pm and 3pm - 11pm shifts. Based on a cross reference of the Monthly Work Schedules submitted for April 18 2021 - May 25, 2021, the daily Person-In-Charge Report from April 18, 2021 - May 25, 2021 and the Timecard Reports dated April 18, 2021- April 30, 2021 and May 1, 2021 - May 25, 2021 for each staff member: 1. On April 24, 25, & 27, 2021 and May 2, 8, 9, 11 & 21, 2021 there was one staff or no staff scheduled to work on the memory care unit during the 7am - 3pm shift. 2. On April 18-23 & 26-30, 2021 there was one staff or no staff scheduled to work on the memory care unit during the 3pm -11pm shift. 3. On May 1-11, 12-20 & 24,25 2021 there was one staff or no staff scheduled to work on the memory care unit during the 3pm -11pm shift.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-1130-C
Description:	Based on a review of staff schedules and accompanying documentation during the night hours the facility failed to ensure that there were at least two direct care staff members awake and on duty at all times in the special care unit who were responsible for the care and supervision of the residents. Evidence: At the time of the inspection there were (10) residents present in the memory care unit. The evidence reflects the dates and times the memory care unit was not staffed with two direct care staff members during the night hours. Based on a cross reference of the Monthly Work Schedules submitted for April 18 2021 - May 25, 2021, the daily Person-In-Charge Reports from April 18, 2021 - May 25, 2021 and the Timecard Reports dated April 18, 2021- April 30, 2021 and May 1, 2021 - May 25, 2021 for each staff member: 1. On April 18, 19, 22-25, 27, 28 &30, 2021, there was one staff or no staff scheduled to work on the memory care unit during the 11pm -7am shift. 2. On May 1-2 & 4-24, 2021 there was one staff or no staff scheduled to work on the memory care unit during the 11pm -7am shift. During the entire month of May, 2021 there were only two days when two staff were scheduled to work on the memory care unit from 11pm -7am.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-290-A
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 on each shift, with an indication of who is in charge at any given time and any absences, substitutions, or other changes noted on the schedule. Evidence: *The Monthly Work Schedules for April 18, 2021-May 25, 2021 submitted by the facility were not updated to reflect absences or days worked for each staff member as indicated by the Timecard Reports during the same time period. The written work schedule was not updated to reflect the following: Staff # 1-4 worked a combined total of (39) thirty nine 7am -3pm shifts. Staff #7 worked one 7am -3pm shift and (2) two 3pm -11pm shifts. Staff #4 worked (9) nine 3pm -11pm shifts. Staff # 8-13 worked a combined total of (19) nineteen 3pm -11pm shifts. Staff # 3-4, #8, #11, #13 worked a combined total of (16) sixteen 11pm -7am shifts. Staff # 5-6 worked a combined total of (17) seventeen 7 -3 shifts. *The names and job classifications for Staff #5 and Staff #6 were not listed on the Monthly Work Schedule.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-C
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 review of the Med Variance Report dated April 18 - May 25, 2021 reflected the following: Resident #1: 1. Upon review of the Med Variance Report, approximately 64 prescription medication doses were administered more than one hour after the facility's standard dosing schedule. 2. Late administration times ranged from approximately 43 minutes to 2.5 hours. a. Staff #3 did not document why medications were administered late. b. Staff #7 documented "7" as the reason for late administration. c. Staff #13 documented, "link" or did not document reason for later administration. Resident #2: 1. Upon review of the Med Variance Report, approximately 20 prescription medication doses administered more than one hour after the facility's standard dosing schedule. 2. Late administration times ranged from approximately 7 minutes to approximately 26 minutes. a. Staff #4 documented, "got here late" as the reason for late administration. b. Staff #7 documented, "4" and "330" as the reason for later administration. c. Staff #16 documented, "late" as the reason for late administration. Resident #3: 3. Upon review of the Med Variance Report, approximately 16 prescription medication doses administered more than one hour after the facility's standard dosing schedule. 4. Late administration times ranged from approximately 13 minutes approximately two hours and 36 minutes. a. Staff #3 documented "7" or did not document a reason for late administration. b. Staff #12 documented, "gave" as the reason for late administration. c. Staff #16 documented, "late" as the reason for late administration. Resident #4: 1. Upon review of the Med Variance Report, approximately 12 prescription medication doses administered more than one hour after the facility's standard dosing schedule. 2. Late administration times range from approximately 30 minutes to approximately 54 minutes. 3. Staff #4 documented, "patient care", Staff #7 documented, "had to assist resident", "6" and "9", Staff #13 documented "link" as to why the medication was administered late. Resident #5: 1. Upon review of the Med Variance Report, approximately 5 prescription medication doses administered more than one hour after the facility's standard dosing schedule. 2. Late administration times was approximately 51 minutes. 3. Staff #16 documented, "late" as to why the medication was administered late.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-D
Description:	Based on 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 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. Upon review of the Medication Administration Records (MAR), no documentation of medication administration or omission was completed on the April 2021 and May 2021 MAR for the following: a. Resident #1: one medication (totaling 3 doses) scheduled 2:00pm on 4/17/-18 and 4/29, 2021, one medication (totaling 2 doses) scheduled for 2:00pm on 4/1 and 4/29, 2021, and one medication totaling two does scheduled for 6:00pm on 4/1 and 4/18, 2021, two medications (totaling 8 doses) scheduled for 2:00pm on 5/6, 5/24-25, and 5/27/2021, and one medication (totaling 2 doses) scheduled for 10:00pm on 5/9 and 5/24/2021. Diagnosis for these medications included muscle spasms, mood stabilizer, insomnia, and diabetes mellitus. b. Resident #2: one medication (totaling 3 doses) scheduled for 2:00pm on 4/17-4/18 and 4/29, 2021, one medication (totaling 6 doses) scheduled for 12:00pm on 5/21 and 2:00pm on 5/6, 5/24-25, 5/27, and 5/31, 2021. Diagnosis for this medication was Parkinson's Disease. c. Resident #3: one medication (totaling 2 doses) scheduled for 7:00pm on 4/2 and 11:00am on 4/21/2021 and one medication (totaling 6 doses) scheduled for 11:00am on 5/10, 5/14, 5/21, 5/24, and 5/28, 2021 and 7:00pm on 5/2/2021. Diagnosis for this medication was yeast infection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-H
Description:	Based on a review of the Medication Administration Records (MAR), the facility failed to document on the medication administration records at the time the medication was administered. Evidence: Upon review of the Med Variance Report dated April 18, 2021 - May 25, 2021, the following was noted: 1. Resident #1: a. Approximately fifty-one doses of prescription medication were not documented at the time of administration. b. Staff #3 documented "late post" and "late but given on time." c. Staff #7 documented, "7 pm forgot to record." 2. Resident #2: a. Approximately seven doses of prescription medications were not documented at the time of administration. b. Staff #3 documented, "late post". 3. Resident #3: a. Approximately 70 doses of prescription medications were not documented at the time of administration. b. Staff #3 documented, "late post, late post but given on time, and "7". c. Staff #7 documented, "late post". 4. Resident #4: a. Approximately fifty-four doses of prescription medications were not documented at the time of administration. b. Staff #7 documented, "late post".
Plan of Correction:	Not available online. Contact Inspector for more information.