VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Spring Arbor of Winchester
2093 Northwestern Pike
Winchester, VA 22603
(540) 662-6883

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: June 22, 2022

Complaint Related: No

Areas Reviewed:

MARK AREAS REVIEWED AREAS OF STANDARDS ? 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 ACCOMMODATIONS AND RELATED PROVISIONS ? 22VAC40-73 BUILDINGS AND GROUND ? 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:

The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. However, violation(s) not related to the (complaint(s)/self-report) but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. Should you have any questions, please contact Rhonda Whitmer, Licensing Inspector at (540) 292-5932 or by email at Rhonda.whitmer@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-460-D
Description:	Based on review of resident?s record and an interview, the facility failed to provide supervision of resident schedules, care, and activities, including specialized needs such as prevention of falls and wandering from the premises. EVIDENCE: 1. On 05/29/2022, communication was received from the facility via email reporting that resident 1 left the facility on 05/28/2022 and was found by a passerby and returned to the facility. 2. On 05/31/2022 the facility submitted a written incident report indicating resident 1 was found at 8:00pm on 05/28/2022 walking west bound on Route 50, and was approximately 30 feet from the driveway of Spring Arbor. 3. The Individualized Service Plan for resident 1 dated 10/04/2021 indicates resident requires hands on assistance by staff to ensure resident is steady and has stability while ambulating. 4. The Individualized Service Plan for resident 1, dated 10/04/2021 indicates resident requires physical assistance of family/staff with wheelchair or walker when entering and exiting the building to ensure safe mobility while at Spring Arbor. 5. A note from resident 1?s chart dated 5/28/2022 at 8:00pm indicates facility received a call that there was a resident walking on Route 50. Staff went to get resident, people picked up resident and brought her back to the facility. Family is to provide 24 hour care until cottage placement. 6. The LI interviewed the Resident Care Director on 06/15/2022 who confirmed resident was found on a gravel area with walker on route 50 a four-lane highway at approximately 8:00pm by a passerby. Resident Care Director indicated resident was last seen sitting in the common area at approximately 7:30pm by staff member 2. 7. The incident report submitted by the facility on 05/31/2022 identified resident 1 needed one on one supervision until being transferred to the safe and secured environment within the facility.
Plan of Correction:	Immediately following the survey, safety practices regarding Missing Residents and Elopements were reviewed with team members by the Cottage Care Director, Resident Care Director, and the Executive Director. In addition, all components of Spring Arbor's June CQE ( Continuing Quality Education) topic Missing Resident Policies and Protocols were addressed during a community in-service on 06/28/2022. All Elopement Risk Screening were reviewed and updated by the Resident Care Director and the Cottage Care Director. These were completed by 07/05/2022. Residents who screened at-risk for elopement were identified on ISPs, on Shift-to-Shift Reports and on ALD Checklists for added team awareness. Reminders of any individual residents at risk for elopement will be addressed at daily Stand-Up and during Shift-to-Shift reports and huddles. Specific interventions in place to maximize individual resident safety will be communicated to team members. Team members are reminded daily to communicate promptly to a Supervisor, Resident Care Director or Cottage Care Director regarding changes in behaviors in any resident, including new exit-seeking verbalizations or activity. Missing Resident/Elopement Drills will be conducted each month, per Spring Arbor policy. The most recent drills conducted were: 05/28/2022 at 8:00pm; 05/30/2022 at 1:30am and 06/28/2022 at 11:38am. An in-service has been scheduled for team members on 07/15/2022 on the topic of Wandering Behaviors. This will be conducted by the Bayada In-house HH/Therapy RN. The Cottage Care Director assessed the resident for Memory Care on 05/31/2022. A new resident History and Physical was completed by her physician on 06/01/2022. A new UAI was completed on 06/03/2022. A new Individualized Service Plan was completed on 06/03/2022.