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 29, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

A complaint was received by VDSS Division of Licensing on 06/09/2023 regarding allegations in the area(s) of: Resident Care and Related Services. 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: 3 The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Rhonda Whitmer, Licensing Inspector at (540) 292-5932 or by email at rhonda.whitmer@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on a review of resident?s record and an interview, the facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or that threatens the life, health, safety, or welfare of any resident. EVIDENCE: 1. The facility ?Incident and Accident Report? dated 05/19/2023 at 6:00am indicates ?Resident A and B started conflicting, resident B made contact with resident A on side of head.? 2. This incident was not reported to the regional licensing office within 24 hours. 3. The LI interviewed staff #2 on 06/29/2023 who confirmed the incident was not reported to the regional licensing office.
Plan of Correction:	Resident Care Director (RCD), Assistant Resident Care Director (ARCD), and Cottage Care Director (CCD) were in-serviced by Executive Director immediately following survey regarding the requirement by Virginia DSS Rules and Regulations to report to the regional licensing office within 24 hours, any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any Resident, also following with a 7-day comprehensive summary of all noted details of the incident. Moving forward, the Resident Care Director (RCD), Assistant Resident Care Director (ARCD) and Cottage Care Director (CCD) will complete the notification to the State Inspector via email within required 24 hours. For comprehensive reports, the above-mentioned team members will complete the report, submit it to the Executive Director for review and signature and the Executive Director will submit it to the State Inspector within required 7-day period.
Standard #:	22VAC40-73-130-A
Complaint related:	Yes
Description:	Based on a review of resident?s record and an interview, the facility failed to report suspected abuse, neglect, or exploitation of residents as mandated reported under 63.2-1606 of the code of Virginia. EVIDENCE: 1. The facility ?Incident and Accident Report? dated 05/19/2023 at 6:00am indicates ?Resident A and B started conflicting, resident B made contact with resident A on side of head.? 2. The LI interviewed staff #2 on 06/29/2023 who confirmed the incident was not reported to the local department of social services or the adult protective services hotline.
Plan of Correction:	RCD, ARCD and CCD were in-serviced by the Executive Director immediately following survey regarding the requirement to report promptly any suspected abuse, neglect, or exploitation of Residents. Moving forward, the Executive Director will ensure all community team members receive Mandated Reporter training upon hire, annually, and as needed as required under ? 63.2-1606 of the Code of Virginia
Standard #:	22VAC40-73-130-B
Complaint related:	Yes
Description:
Plan of Correction:	RCD, ARCD and CCD were in-serviced by the Executive Director immediately following this survey regarding the requirement to notify the Resident?s next of kin, legal representative, designated contact person, case manager, and any responsible social agency, as appropriate. RCD, ARCD, CCD will complete in-service training with all resident care team members in the community regarding the appropriate notification requirements. Moving forward, RCD and CCD will review incident reports for completion as well as verify correct notifications. The Executive Director will then review incident reports for completion prior to filing.
Standard #:	22VAC40-73-320-A
Complaint related:	No
Description:	Based on review of resident?s record, the facility failed to ensure a physical examination by an independent physician is completed within 30 days preceding admission. EVIDENCE: 1. The physical examination report date of examination for resident B is 01/30/2023 and resident B was admitted on 04/23/2023.
Plan of Correction:	RCD, ARCD, CCD and Sales and Marketing Director in-serviced by Executive Director immediately following this survey regarding thorough review of Health & Physical documentation, completed by independent physicians, for accuracy and compliance with Virginia DSS Rules and Regulations. Moving forward, Sales and Marketing Director will review Health & Physical documentation prior to resident?s move in date. Documentation will then be reviewed by the RCD, ARCD, and/or CCD. Lastly, the Executive Director will review for completion prior to admission.
Standard #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on a review of resident?s record, the facility failed to ensure the Uniform Assessment Instrument is completed annually as required. EVIDENCE: The Uniform Assessment Instrument for resident A, admitted 05/07/2019 is dated 06/03/2022.
Plan of Correction:	The Uniform Assessment Instrument (UAI) for Resident A, was completed at time of move- in, at 30-days of move-in and annually as required. The most recent UAI was completed on 06/03/2023 however, it was not placed in the Resident?s medical chart at the time of completion. RCD, ARCD and CCD were in-serviced by Executive Director immediately following this survey regarding immediate filing of UAIs in Residents medical records upon completion. Executive Director is completing an audit of all Cottage Resident?s medical charts to ensure UAIs are complete, current, and accurate based on their individual needs and filed in their respective charts as required. Moving forward, RCD, ARCD and CCD will utilize a tracking system of all state required documents. It will be checked frequently to maintain compliance with Virginia DSS Rules and Regulations.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on a review of residents? record, the facility failed to ensure the Individualized Service Plan is updated at least once every 12 months as required. EVIDENCE: The Individualized Service Plan for resident A, admitted 05/07/2019 is dated 06/03/2022.
Plan of Correction:	The Individualized Service Plan (ISP) for Resident A, was completed at time of move-in, at 30-days of move-in and annually as required. The most recent ISP was completed on 06/03/2023 however, it was not placed in the Resident?s medical chart at the time of completion. RCD, ARCD and CCD immediately following this survey in-serviced by Executive Director regarding immediate filing of ISPs in Residents medical charts upon completion. Executive Director is completing an audit of all Cottage Resident?s medical files to ensure ISPs are complete, current, and accurate based on their individual needs and filed in their respective charts as required. Moving forward, RCD, ARCD and CCD will utilize a tracking system of all state required documents. It will be checked frequently to maintain compliance with Virginia DSS Rules and Regulations.
Standard #:	22VAC40-73-470-F
Complaint related:	Yes
Description:	Based on review of resident?s record and an interview, the facility failed to ensure medical attention from a licensed health care professional was secured immediately when the resident suffers serious accident, injury, illness, or medical condition, other there is reason to suspect that such has occurred. EVIDENCE: 1. The facility ?Incident and Accident Report? dated 05/19/2023 at 6:00am indicates ?Resident A and B started conflicting, resident B made contact with resident A on side of head.? 2. The facility ?Incident and Accident Report? dated 05/19/2023 at 6:00am indicates resident A was assessed by a registered medication aide. 3. The facility ?Incident and Accident Report? dated 05/19/2023 at 6:00am section indicates vital signs were not obtained, resident was not sent to the hospital and the section for notification to physician is left blank. 4. The LI interviewed staff #2 on 06/29/2023 who confirmed resident was not seen by a licensed health care professional immediately after the incident and resident A?s physician was not notified.
Plan of Correction:	RCD, ARCD and CCD in-serviced by Executive Director immediately following this survey regarding the requirement to notify the Resident?s physician as well as ensuring medical attention from a licensed health care professional. RCD, ARCD, CCD will complete in-service training with all registered medication aides in the community regarding the appropriate follow up requirements following resident incidents. Moving forward, RCD and CCD will review incident reports for completion as well as verify correct notifications. The Executive Director will then review incident reports for completion prior to filing.