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: Oct. 10, 2023

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 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

Technical Assistance:

Please submit the renewal application 30 days prior to the date the current license expires. A new license cannot be issued without a renewal application.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 8:20 am on 10/10/2023 and exited at 3:45 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection Number of residents present at the facility at the beginning of the inspection: 90 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed medication administration. LI observed residents eating breakfast and lunch. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-40-A
Description:	Based upon documentation and record review, the facility failed to comply with their own policies and procedures. Evidence: 1. On 10/10/2023 LI reviewed the Medication Management plan which states under the Controlled Substance section ?it shall be the medication person?s responsibility to complete the Individual Controlled Drug Record (ICDR) for each medication administered.? 2. The ICDR for Resident #3 was not completed for Oxycodone administered at approximately 10 pm on 10/9/2023.
Plan of Correction:	RCD reviewed and in-serviced all employees certified/licensed to administer medications, on the company Medication Management Plan on October 18, 2023. Moving forward, RCD, ARCD and/or CCD will ensure training and/or review of company Medication Management Plan with all new employees who are certified/licensed to administer medications upon hire, annually and as needed.
Standard #:	22VAC40-73-260-A
Description:	Based upon record reviews, the facility failed to ensure each direct care staff member maintained current certification in first aid for one of five staff records reviewed. Evidence: 1. 10/10/2023 Licensing Inspector (LI) observed that the record for Staff #3 did not contain a current first aid certification.
Plan of Correction:	Staff #3 is scheduled to attend the required First Aid Certification on October 31, 2023. Business Office Manager (BOM) and/or Designee will audit direct care staff records to ensure First Aid Certifications are current/up to date by October 31, 2023. Moving forward the BOM will audit direct care staff records to ensure First Aid Certifications are current/up to date.
Standard #:	22VAC40-73-680-I
Description:	Based upon record reviews the facility failed to ensure that Medication Administration Records (MARs) included date and time given and initials of direct care staff administering the medication, and effectiveness for as needed (PRN) medications for three of eight residents. Evidence: 1. 10/10/2023 LI observed that the October 2023 MAR for Resident #3 did not have initials of direct care staff who administered medications at approximately 7 pm on 10/9/2023. 2. 10/10/2023 LI observed that the October 2023 MAR for Resident for Resident #2 did not have initials of direct staff who administered medication at approximately 10 pm on 10/9/2023. 3. 10/10/2023 LI observed that the October 2023 MAR did not include the effectiveness of a PRN medication administered at approximately 5:40 am on 10/10/2023 to Resident #1.
Plan of Correction:	Resident Care Director (RCD) in-serviced/retrained all staff members, certified/licensed to administer medication, regarding appropriate and required documentation of Medication Administration Record on October 18, 2023. Moving forward, RCD, Assistance Resident Care Director (ARCD) and/or Cottage Care Director (CCD) will ensure training and/or review of policies/regulations of appropriate Medication Administration Documentation with all new employees who are certified/licensed to administer medication upon hire, annually, and as needed.