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: May 31, 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 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 8:45AM until 2:30PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on staff record review, the facility failed to ensure that prior to coming in contact with residents that each staff person on or within seven days prior to the first day of work at the facility submitted the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. EVIDENCE: The date of hire for staff persons 1, 2, 3 and 4 is 03/18/2023; however, the TB assessments in the records for these staff persons were all dated 04/10/2023.
Plan of Correction:	ED/BOM will ensure that all TB screening are completed within 7 days of hire
Standard #:	22VAC40-73-290-B
Description:	Based on observations of the facility physical plant, the facility failed to follow their person in charge posting procedures. EVIDENCE: At approximately 8:45AM on the day of inspection, the person in charge posting was observed to contain the names of staff in charge for the previous day (05/30/2023).
Plan of Correction:	Security will maintain person in charge posting by 6AM daily
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure individualized service plans (ISPs) were completed as required. EVIDENCE: 1. The record for resident 5 contains a signed physician?s order, dated 01/03/2023, for the resident?s diet to be upgraded to mechanical soft and an additional signed physician?s order, dated 01/17/2023, for the resident to continue with the mechanical soft diet and request to allow hard-boiled eggs. 2. The ISP for resident 5, dated 07/28/2022, contains documentation that the resident is to be receive a regular diet and does not include information about a mechanical soft diet. This was also noted by staff 6.
Plan of Correction:	DON/DSD will ensure that all Diet orders are communicated during stand up to ensure accuracy for all ISP's
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, staff interview and document review, the facility failed to ensure that medications were administered in accordance with physicians? instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing (VBON). EVIDENCE: 1. The current medication aide curriculum revised by the Virginia Board of Nursing in 2022 contains the following documentation on page 53: ?Non-Insulin Injections a. medication aides may not administer pursuant to 18VAC90-60-110(B)(5)?. 2. The May 2023 medication administration record (MAR) for resident 5 contains documentation that the resident receives Trulicity, a non-insulin injection, once a week. 3. The May 2023 MAR indicates that the resident received a Trulicity injection on 05/03/2023, 05/10/2023, 05/17/2023 and 05/24/2023; however, the injections were all administered by registered medication aides (RMAs). Interview with staff 6 confirmed that this is accurate.
Plan of Correction:	DON will ensure/educate all RMA's on all non-insulin protocols
Standard #:	22VAC40-73-700-2
Description:	Based on observations of the facility physical plant, the facility failed to post a ?No Smoking-Oxygen in Use? sign in all rooms where oxygen is in use. EVIDENCE: An oxygen concentrator was observed in use by the resident who resides in room B-205 on the day of inspection. A ?No Smoking-Oxygen in Use? sign was not posted for this room.
Plan of Correction:	ED/DON will ensure that all oxygen in use signage is in place.
Standard #:	22VAC40-73-860-I
Description:	Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area. EVIDENCE: During on-site inspection, two licensing inspectors (LIs) noted in the facility?s safe, secure unit a can of Air Lift Tropical Air Fresher sitting out in the bathroom across from room H-111 and the sink in the bathroom across from room H-124 was unlocked and contained a can of Spartan TB-Cide Quat Cleaner and a container of Clorox Hydrogen Peroxide Disinfectant wipes.
Plan of Correction:	ED/DON will ensure that all cleaning supplies are properly locked in all cabinets
Standard #:	22VAC40-73-870-A
Description:	Based on observations of the facility physical plant, the facility failed to maintain the exterior and interior of the building in good repair. EVIDENCE: 1. The front area of the building above the green awnings was noted to have an area of wall damage. 2. The carpet in the hallway outside of the library and the A through D cottages was noted to have multiple stains. 3. The carpet in the hallway outside of E cottage was noted to have areas of staining under the windows and in the middle of the hall. 4. The carpet in the hallway outside of room G-102 was noted to have staining. 5. The carpet in the hallway in F cottage outside of room F-102 was noted to have areas of staining. 6. The carpet outside the main doors at the threshold to the dining room near the bulletin board was noted to be stained.
Plan of Correction:	The facility will obtain professional carpet cleaning services to remove stain from carpet.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to ensure that criminal history record reports were obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. Staff 1 was hired on 03/18/2023. The Virginia State Police (VSP) criminal record exchange document for staff 1 indicates that the results of the search were not received until 05/16/2023. 2. Staff persons 7 and 8 were hired on 03/18/2023. The VSP criminal record exchange documents for staff persons 7 and 8 indicate that the results of the search were not received until 05/31/2023 for both staff. 3. Staff persons 9, 10 and 11 were hired on 03/18/2023; however, the VSP criminal record exchange documents for these staff persons provided during on-site inspection on 05/31/2023 contained documentation that the status of the searches is that ?transaction is being processed? indicating that results have not yet been received.
Plan of Correction:	ED/BOM will ensure that all Background checks are Completed per state Requirements.