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: Aug. 16, 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: Renewal Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 08/16/2023 8:50AM until 3:45PM 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: 88 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: 5 Number of interviews conducted with staff: 5 Observations by licensing inspectors: medication pass, medication cart audits, activities 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 #:	22VAC40-73-1040-B
Description:	Based on resident record review, staff and resident interview, and observation, the facility failed to ensure that there are protective devices on the bedroom windows of residents with serious cognitive impairments and on windows in common areas accessible to these residents to prevent the windows from being opened wide enough for a resident to crawl through. EVIDENCE: 1. The record for resident 10, admitted to the facility on 05/22/2023, contains documentation that the resident was a patient in the hospital from 05/01/2023 until 05/22/2023. 2. Notes from Collateral 2 includes the following information regarding the resident: resident has a history of two traumatic brain injuries (TBI) the first being in 2006 and had noticeable memory loss which included getting lost in an area of town where he is very familiar with surroundings and a second in 2021 where the resident began to show more personality changes, more irritability, low frustration tolerance, more aggressive at intervals and at one time experienced visual hallucinations of people in his house and unknown car in his driveway; 05/03/2023, resident is oriented only to self and does not know why he is in the hospital; 05/05/2023, resident is oriented only to self and when asked where he was at the resident responded that he was at the counter (nurses? station) and supposed to meet some people to go elsewhere and that he has to help do some carpentry work; 05/06/2023, resident is oriented only to self and knows he is at hospital; however, the resident had no idea why he was at the hospital; 05/07/2023, resident is oriented only to self and 05/08/2023, resident is orientated only to self. In addition, documentation in the record for resident 10 from Collateral 2 stated on 05/10/2023 that the resident will need placement in an appropriate memory care unit. The documentation from Collateral 2 that includes this information contains a fax time stamp of 05/22/2023 which is the day that the resident was admitted to the facility. 3. The uniform assessment instrument (UAI) for resident 10, with an assessment date of 05/16/2023 and a reassessment date of 06/08/2023, indicates that the resident is disoriented to all spheres (person, place, and time) some of the time. The individualized service plan (ISP) for the resident, dated 05/23/2023, indicates that the resident is disoriented to all spheres some of the time. 4. The record for resident 10 contains documentation that the resident started receiving occupational therapy (OT) on 06/07/2023 and that facility staff had reported to OT that the resident is having trouble finding his room and locating necessary places throughout the facility. OT notes for the resident indicate that the goals of OT for the resident would be that the resident will be able to locate his room with stand-by-assist and visual cues as needed demonstrating good safety and that the resident will be able to locate his room and all necessary facilities such as bathroom and dining room, throughout the facility using visual aides as needed demonstrating good safety. (see additional documentation)
Plan of Correction:	Resident at the time of inspection was re-assessed and placed on secured unit per MD orders. DON will ensure that all ISP?s are updated as needed for any LOC.
Standard #:	22VAC40-73-70-A
Description:	Based on resident record review and collateral documentation, the facility failed 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. EVIDENCE: 1. The record for resident 10 contains a facility staff note, dated 07/14/2023 at 6:45AM, that the resident was brought back to the facility by Collateral 1 and that the resident had wandered off facility property with the intention of finding his wife. The note also states that once the resident was brought back to the facility, he was given a PRN anxiety medication, shown to his room multiple times throughout the evening and that the resident finally settled down around 12:00AM. 2. Incident report provided by Collateral 1 to the licensing inspector states that on 07/13/2023 from 8:31PM until 9:00PM Collateral 1 responded to the 900 block of College Street Bedford, Virginia 24523 in reference to a suspicious male that was walking in the area. Upon Collateral 1?s arrival, Collateral 1 noted that the individual appeared confused and was making statements that were not making sense. The resident had several pieces of paper in his pockets with phone numbers along with a single key with a key chain that contained the facility?s name and Collateral 1 took the individual to the facility. Collateral 1 met with facility staff that identified the individual as a resident at the facility. 3. The aforementioned information was not reported to the regional licensing office.
Plan of Correction:	ED/DON will in-service nursing staff to correctly document. DON will ensure and monitor daily for accuracy. Residents H&P states resident is able to self-preservation on admission. Resident was re-assessed an appropriate documentation was completed the date of this inspection; resident was placed on secured unit per MD orders on 8.24.2023
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated as needed for a significant change of a resident?s condition. EVIDENCE: 1. Resident 10 was admitted to the facility on 05/22/2023. The record for resident 10 contains a facility staff note, dated 06/06/2023 at 4:30PM, that the resident was pacing down halls and calling his wife over and over; resident was provided with one-on-one from staff and an additional facility staff note, dated 06/22/2023 at 11:30PM, indicated that the resident was trying to leave the facility out the front door, the resident was agitated, cursed at three staff members who were trying to redirect him and that staff assisted him back into the facility and to his room. 2. A physician progress note, dated 06/20/2023, included documentation that facility staff had reported to the physician that the resident had increased pacing for the past three days. 3. The record for resident 10 also contains a facility staff note, dated 07/14/2023 at 6:45AM, that the resident was brought back to the facility by Collateral 1 and that the resident had wandered off facility property with the intention of finding his wife. The note also states that once the resident was brought back to the facility, he was given a PRN anxiety medication, shown to his room multiple times throughout the evening and that the resident finally settled down around 12:00AM. Additional information provided by Collateral 1, indicated that they were made aware of a suspicious male in the 900 block of College Street Bedford, Virginia through a report at 8:31PM on 07/13/2023 and identified the male as living at the facility. Collateral 1 brought the resident to the facility and facility staff identified the resident as a resident of the facility. 4. A physician progress note, dated 07/18/2023, included documentation that the resident was being seen by the physician at request of facility staff as the resident had recently left the facility late in the afternoon/early evening, had to be returned by the police and that staff had reported that the resident?s confusion worsens with an increase in pacing and wandering daily after 4:00PM and that the resident has been experiencing an increase in insomnia. 5. The ISP in the record for resident 10, dated 05/23/2023, did not include information regarding the resident?s wandering, pacing and exit-seeking behaviors.
Plan of Correction:	DON will ensure that all ISP;s are updated as needed.
Standard #:	22VAC40-73-640-A
Description:	Based on observations of the facility medication carts and policy review, the facility failed to implement their medication management plan regarding methods to ensure accurate counts of controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The facility medication management plan provided to the licensing inspector on the day of inspection has documentation that ?During shift change, all narcotics, cards, bottles, sheets are counted and recorded by the oncoming and off going medication aide/nurse. The oncoming and off going medication persons both sign off on the accurate counts of all narcotics on the narcotic administration record?. 2. The Controlled Drug Shift Count Record for the A Cottage Medication Cart for August 2023 was noted to not have signatures for the ?nurse off 11-7? on 8/01/2023, ?nurse on and nurse off 3-11? on 08/04/2023, ?nurse off 3-11 and nurse on 11-7? on 08/11/2023, ?nurse on 11-7? on 08/13/2023 and ?nurse off 11-7? on 08/14/2023. 3. The Controlled Drug Shift Count Record for the B Cottage Medication Cart for August 2023 was noted to not have signatures for the ?nurse on 11-7? 11- Shift on 8/13/2023, ?nurse off 11-7? 7-3 Shift on 8/14/2023, ?nurse on 11-7? 11- Shift on 8/14/2023, and ?nurse off 11-7? on 7-3 Shift on 8/15/2023.
Plan of Correction:	DON will ensure that all signature on and off shifts are completed daily and monitored and audited for completion.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observations of the facility physical plant, the facility failed to ensure that storage areas for medications were locked. EVIDENCE: At approximately 11:14AM on the day of inspection, staff person 1 left the nursing station at the end of the hallway by A cottage to locate a resident that was due to receive medications. Two licensing inspectors observed that the medication refrigerator located in the nursing station was left unlocked. The refrigerator contained a Novolog Insulin vial for resident 8, a Lantus Insulin vial for resident 15, 2 boxes of Basaglar Insulin Kwik Pens for resident 16, and a bottle of Lorazepm Intensol Oral Concentrate for resident 17.
Plan of Correction:	DON will in service all nursing staff to close the nursing station door when leaving even if the license inspector or any other staff are in the office.
Standard #:	22VAC40-73-660-B
Description:	Based on observations of the physical plant and resident record reviews, the facility failed to ensure that the medications kept in resident?s rooms were stored in an out of sight location in the resident?s room and only for residents who have been assessed as capable of self-administering their own medications. EVIDENCE: 1. On 08/16/2023 at approximately 9:22AM, two licensing inspectors (LI?s) observed a container of Hempvana Pain Relief Cream Trolamine Salicylate 10% sitting out on the dresser in the room for resident 8. The uniform assessment instrument (UAI), dated 04/15/2023, has documentation that resident 8?s medications are administered to them by a lay person and the box below indicates that facility registered medication aids (RMAs) and licensed practical nurses (LPNs) administer the medications. The record for resident 8 did not contain a physician?s order for Hempvana Pain Relief Cream Trolamine Salicylate 10%. Staff person 3 confirmed that the facility administers the resident?s medication. 2. On 8/16/2023 at approximately 9:33AM, two LIs observed a bottle of H Chlor 12 .125% Sodium Hypochlorite solution in the bathroom on an open shelf in the room of resident 7. The UAI, dated 8/1/2023, has documentation that resident 7?s medications are administered to them by a lay person and the box below indicates that facility registered medication aides (RMAs) and licensed practical nurses (LPN) administer the medications. The record for resident 7 did not contain a physician?s order for the H Chlor 12 .125% Sodium Hypochlorite solution. Staff person 3 confirmed that the facility administers the resident?s medication. 3. On 8/16/2023 at approximately 9:38AM, two LIs observed a tube of Clobetasol Propionate Cream USP 0.05% and a tube of Equate Athlete?s Foot Terbinafine Hydrochloride 1% on the nightstand near the bed in the room of resident 5. The UAI, dated 4/1/2023, has documentation that resident 5?s medications are administered to them by a lay person and the box below indicates that facility registered medication aides (RMAs) and licensed practical nurses (LPN) administer the medications. The record for resident 5 did not contain a physician?s order for both Clobetasol Propionate Cream USP 0.05% and Equate Athlete?s Foot Terbinafine Hydrochloride 1%. Staff person 3 confirmed that the facility administers the resident?s medication. 4. On 08/16/2023 at approximately 9:46AM, two LIs observed a bottle of CVS Health 8 HR Muscle Aches & Pain Acetaminophen Extended Relief 650mg and a bottle of Max Strength Aspercreme with 4% Lidocaine Pain Relief Liquid sitting out on a table beside a chair in the living room for resident 6. The UAI for resident 6, dated 03/01/2023, contains documentation that the resident?s medications are administered to them by a layperson and the box below indicates that facility registered medication aids (RMA?s) and LPN?s administer the medications. The record for resident 6 did not contain a physician?s order for the aforementioned medications. Staff 3 confirmed in an interview that the facility administers resident 6?s medications.
Plan of Correction:	ED/DON/Nursing staff will ensure and conduct weekly room sweeps to ensure that resident of families have not brought in any OTC medications that are not on their MAR. DON will obtain orders as needed for these.
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: 1. A can of Comet Cleaner and a can of Xcelente Multipurpose Cleaner was observed sitting out on the glove box that was hanging on the wall in the bathroom across from room H-11 on the facility safe, secure unit. 2. The first door to the right of the stairway in the lower level/basement hallway was noted to be opened and the room contained a bottle of Fresh Laundry Sanitizer, a bottle of Great Value Glass Cleaner and a bottle of Clean by Peroxy All Purpose Hydrogen Peroxide Based Cleaner. A door leading into a storage area was also open and the room contained a bottle of Consume Mirco-Muscle General Purpose Degreaser. 3. The second door to the right of the stairway in the lower level/basement hallway was noted to be unlocked and the room contained a bottle of Clean by Peroxy All Purpose Hydrogen Peroxide Based Cleaner, a bottle of Chlor-Glo Bleach and a bottle of Hoover Permanent Stain Removal. 4. The maintenance room to the left of the stairway in the lower level/basement hallway was noted to be opened and the room contained a bottle of Harvey?s Thread Cutting Oil, a can of Mainline CPVC & PVC Plastic pipe cement, several cans of Oatey Purple Primer and Oatey Stain-Free Plumbers Putty.
Plan of Correction:	ED/DON/Nursing staff will ensure that all cleaning supplies are stored appropriately. Maintenance will ensure that all doors in basement is closed and locked at all times and appropriate locks are placed on doors to basement as recommended.
Standard #:	22VAC40-73-860-J
Description:	Based on observations of the facility physical plant, the facility failed to ensure that residents who keep their own cleaning supplies or other hazardous materials in their rooms stored them in an out-of-sight place so that they are not accessible to other residents. EVIDENCE: 1. The door to room A-102 was noted to be opened on the day of inspection and a can of Lysol Spray was observed sitting out on the sink in the bathroom. The resident who resides in this room was not present in the room at the time of this observation. 2. The door to room A-206 was noted to be opened on the day of inspection and a can of Lysol Spray, a can of Airlift Air Freshner, a can of Renuzit Dream Garden Air Freshner and a bottle of Febreeze were observed sitting out on the shelf in the bathroom. The resident who resides in this room was not present in the room at the time of this observation. 3. The door to room D-203 was noted to be opened on the day of inspection and a container of True Living Disinfectant Wipes was observed sitting out on the windowsill of the living room. The resident who resides in this room was noted to be in a separate room sleeping at the time of this observation.
Plan of Correction:	ED will send communication to all residents on AL that all sprays, etc are stored and put away at all times.
Standard #:	22VAC40-73-870-A
Description:	Based on observation of the facility physical plant, the facility failed to ensure the interior of the building is maintained in good repair and kept clean. EVIDENCE: 1. An overhead cabinet in room B-107 close to the window was noted to have a large area by the hinges that was damp and stained and the bottom corner of the cabinet close to the hinges was noted to be separating from the bottom base of the cabinet. 2. During a walk-through of the facility physical plant, the following was observed from 9:18AM through 9:51AM during the on-site inspection: the ceiling in room A206, above the window in the right corner of the room, was noted to have a circular stain on a ceiling tile; the ceiling in the hallway near room B105, near the light fixture, was noted to have a stain; the ceiling in the stairwell in Cottage D on the 2nd floor, directly off the elevator, was noted to have a stain near the window and the ceiling in the walkway to Memory Care from the main building was noted to have multiple stains that were numerous sizes.
Plan of Correction:	Maintenance/ED/SMD will ensure during weekly room checks that all cabinets are looked at, as this room is not currently occupied.
Standard #:	22VAC40-73-880-C
Description:	Based on observation during a tour of the facility physical plant, the facility failed to ensure that the temperature in all areas used by residents does not exceed 80 degrees Fahrenheit. EVIDENCE: During a walk-through of the facility?s assisted living building with staff 7 during on-site inspection on 08/16/2023, the licensing inspector (LI) and staff 7 recorded the following temperatures that exceeded 80 degrees Fahrenheit: 83 degrees Fahrenheit in the walkway/hall outside of the entrance of C cottage at 10:33AM; 81 degrees Fahrenheit in the walkway/hall outside of the entrance into D cottage at 10:33AM; 80.5 degrees Fahrenheit in the walkway/hall outside of the entrance into B cottage at 10:33AM; 83 degrees Fahrenheit in the library at 10:30AM; 81.5 degrees Fahrenheit in the activities room/dining room beside A/B/C/D cottages at 10:30AM; and 87 degrees Fahrenheit in the sitting area/common area between F/G cottage and E cottage near the elevator at 10:39AM.
Plan of Correction:	Facility has gotten A/C working.