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 29, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/29/2024 11:30AM until 2:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/15/2024 regarding allegations in the area of: resident care and related services. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. 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 #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1 contains a physician?s order for quetiapine 50MG, dated 02/27/2024, take one (1) tablet every six (6) hours as needed (PRN) for severe anxiety/agitation. 2. The April 2024 medication administration record (MAR) for the resident indicates that on 04/11/2024 staff person 2 administered PRN quetiapine 50MG to the resident at 4:14PM and at 9:17PM; however, there had not been six hours since the resident received the first dose of quetiapine 50MG. Interview with staff person 1 on 06/04/2024 confirmed that this was accurate.
Plan of Correction:	DON/ED will Inservice all RMA?s on The correct medication administration For PRN?s and educate all RMA?s on The documentation of physicians Orders for PRN medication form.
Standard #:	22VAC40-73-680-K
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure the use of PRN medications is prohibited, unless the resident is capable of determining when the medication is needed, licensed health care professionals administer the PRN medications; or medication aides administer the PRN medication when the facility has obtained from the resident?s physician or other prescriber a detailed medication order and the order shall include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist. EVIDENCE: 1. Interview with staff person 1 confirmed that resident 1 has a diagnosis of dementia and would not be capable of determining when a PRN medication is needed. Resident 1 resided in the facility?s safe, secure unit. 2. The record for resident 1 contains a physician?s order, dated 02/27/2024, for acetaminophen 325MG take two (2) tablets every six (6) hours as needed (PRN) for pain do not exceed 3,000MG within 24 hours. The March 2024 medication administration record (MAR) for resident 1 indicates that registered medication aides (RMAs) administered the resident acetaminophen one time on 03/05/2024, one time on 03/08/2024, and three times on 03/12/2024; however, the physician?s order does not include symptoms that indicate the use of the medication and directions as to what to do if symptoms persist. 3. The record for resident 1 contains physician?s orders for the following PRN medications: hydroxyzine pamoate 25MG, dated 02/27/2024, take one (1) capsule every eight (8) hours as needed (PRN) for anxiety/agitation; quetiapine 50MG, dated 02/27/2024, take one (1) tablet every six (6) hours as needed (PRN) for severe anxiety/agitation; lorazepam 0.5MG, dated 03/28/2024, take one (1) tablet every six (6) hours as needed (PRN) for anxiety/agitation; and lorazepam 0.5MG, dated 04/11/2024, take one (1) tablet every six (6) hours as needed (PRN) for anxiety/agitation. The March 2024 MAR (03/01/2024 through 03/31/2024) for resident 1 indicates that hydroxyzine pamoate 25MG was administered to the resident by RMAs 22 times, quetiapine 50MG was administered to the resident by RMAs 19 times, and lorazepam 0.5MG was administered to the resident by RMAs 4 times throughout the month of March 2024. The April 2024 MAR (04/01/2024 through 04/17/2024) for resident 1 indicates that hydroxyzine pamoate 25MG was administered to the resident by RMAs 2 times, quetiapine 50MG was administered to the resident by RMAs 11 times, and lorazepam 0.5MG was administered to the resident by RMAs 16 times throughout the month of April 2024. 4. The physician?s orders for the aforementioned PRN medications that were administered by RMAs throughout March 2024 and April 2024 do not include symptoms that indicate the use of the aforementioned PRN medications and directions as to what to do if symptoms persist.
Plan of Correction:	DON will complete upon admission and recert all PRNs every 6 month and as needed for accurate documentation for all RMAs to be able to identify symptoms, dosages, timeframes, directions if symptoms persist.