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: June 11, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/11/2024 1:30PM until 2:20PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 06/10/2024 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 supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self report but identified during the course of the investigation can also 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
Description:	Based on resident record review and staff and resident 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 licensing inspector (LI) received an email from staff person 1 on 06/10/2024 that resident 1 had reported to staff person 2 that they believed they had not received their nighttime medications on 06/09/2024. 2. Staff person 2 verified through interview with staff person 3 and the resident?s medication administration record (MAR) that the resident did not receive the following nighttime medications on 06/09/2024: donepezil 5MG, acetaminophen 325MG (take two tablets), docustate sod 100MG, diazepam 2MG and imipramine 25MG (take two tablets). It was verified with staff persons 1 and 2 that this is accurate.
Plan of Correction:	ED/DON will review MAR report daily in stand up from the previous day to ensure accuracy. ED/DON will sign off daily on the MAR report and place it in a binder for documentation.