VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Spring Oak Bedford
931 Ashland Ave
Bedford, VA 24523
(540) 586-8232

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Dec. 22, 2022

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 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Initial Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/22/2022 10:00AM until 12:45PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-870-A
Description:	Based on observation during a tour of the buildings, the facility failed to maintain and keep clean the interior and exterior of the building. EVIDENCE: 1. During on-site inspection on 12/22/2022, it was noted by the licensing inspector that the doors at the front entrance of the facility were damaged and not operating correctly. 2. During on-site inspection on 12/22/2022, it was confirmed that the facility?s sprinkler system and fire alarm system have not been maintained to meet current required guidelines (Collateral 1). 3. Multiple windows located in both dining rooms in the facility?s safe, secure unit were noted to be unclean. 4. The stucco on the front of the building was chipped in various areas on the left and right sides of the main entrance into the building along with multiple areas of a dark colored substances along the outside of the building. 5. The top of the wall and ceiling in the back left corner of the dining/activity room was noted to have chipping paint. 6. Numerous stains were observed on the carpet in front and down the hallways in A, B, C, D, E, F, and G cottages as well as numerous scuffs on the walls down the hallways in A, B, C, D, E, F, and G cottages. 7. Numerous areas were observed of chipped paint on the walls and ceiling near and around the murals in the formal dining room. 8. The exterior of the assisted living building was observed of having brown and orange stains along the bottom of the building in various locations and cracked sidewalks in various locations.
Plan of Correction:	1. Front entrance doors have been replaced (2-28-2023) 2. Sprinkler system and fire alarm will be maintained to meet required guidelines (2-28-2023) 3. Windows will be cleaned as needed (3-31-2023) 4. The stucco in front of the building in spots of building will be cleaned as best as possible and touched up with paint (5-31-2023) 5. Ceiling in activity room will be painted so there is no chipped paint (4-30-2023) 6. Stains in carpet in all cottages will be cleaned and wall paint in all cottages will be maintained (5-31-2023) 7. Dining room paint will be maintained and chips will be fixed (5-31-2023) 8. Exterior building brown and orange stains along the bottom will be cleaned and touched up with paint (5-31-2023)
Standard #:	22VAC40-73-950-A
Description:	Based on document review and interview, the facility failed to ensure there was documentation of initial contact with the local emergency coordinator to determine the requirements of the standard. EVIDENCE: Interview with staff 1 during on-site initial inspection on 12/22/2022 confirmed that there has been no initial contact with the local emergency coordinator to determine local disaster risks, communitywide plans to address different disasters and emergency situations, and assistance, if any, that the local emergency management office will provide to the facility in an emergency.
Plan of Correction:	Facility will contact the emergency coordinator to plan and address emergency situations
Standard #:	22VAC40-73-960-A
Description:	Based on staff interview, the facility failed to ensure its written plan for fire and emergency evacuation that is to be followed in the event of a fire or other emergency has been approved by the appropriate fire official. EVIDENCE: Interview with staff 1 during on-site initial inspection on 12/222/2022 revealed that the facility?s written plan for fire and emergency evacuation has been submitted to the appropriate fire official; however, the aforementioned plan has not yet been approved by the fire official.
Plan of Correction:	Fire and emergency evacuation will be followed and approved by appropriate official.