VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Spring Oak Louisa
440 West Main Street
Louisa, VA 23093
(540) 967-4600

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: July 13, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Time code or duration of one activity not documented, and Family Visitation window cannot count toward total activity hours (sufficient hours without it)

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: 7-13-2023, 10:11a.m. ? 1:07p.m. 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: 23 Number of resident records reviewed: 7 Number of staff records reviewed: 3 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review and interview, the facility failed to ensure the physical examination contained a description of the person?s reaction to known allergies. Evidence: 1. Resident #1?s physical examination dated 11-15-2022 documented codeine as an allergy, but no description of reaction to the allergy. 2. Staff #1 acknowledged the allergy reaction was not described on the physical examination for Resident #1.
Plan of Correction:	ED/DON when reviewing the initial history and physical paperwork will ensure that any allergies have reactions documented on the paperwork from the PCP, to ensure resident safety.
Standard #:	22VAC40-73-450-F
Description:	Based on record review and interview with staff, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. Resident #3?s Observation notes dated 6-07-2023 documented that Resident #3 had a fall on 6-06-2023. Per the notes, ?Resident [#3] was taken to the hospital yesterday for a fall. Returned last night and discharge papers say she has a fracture in her right hip?? 2. Resident #3?s ISP dated 6-01-2023 did not reflect changes following the fall, including any interventions or changes in care. Per Resident #3?s healthcare notes by the resident?s primary care provider, ?Discussed fall risk and safety precautions with patient and staff.? 3. No changes were updated on Resident #3?s ISP despite the resident?s recent fall in June 2023.
Plan of Correction:	ED/DON will ensure that all ISP?s are updated as needed, Interventions will be updated as needed on the care plans to reflect the needs of each individual resident to ensure that the correct care is being followed per PCP recommendations.