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: July 22, 2024 and July 23, 2024

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 GROUNDS 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(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/22/2024 7:54AM until 3:50PM and 07/23/2024 8:05AM until 10:45AM 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: 85 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 5 Observations by licensing inspector: morning medication administration, medication cart audits, activity, noon-time meal 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 #:	22VAC40-73-280-C
Description:	Based on document review and staff interview, the facility failed to ensure an adequate number of staff persons shall be on the premises at all times to implement the approved fire and emergency evacuation plan. EVIDENCE: During on-site inspection, interviews with staff persons 4 and 5 revealed that the facility does not have documentation of and is unaware of the adequate number of staff persons that are needed on the premises at all times to implement its approved fire and emergency evacuation plan.
Plan of Correction:	ED or designee will ensure during monthly safety committee meetings that management will discuss current resident acuity levels and determine the appropriate number of staff persons needed on the premises at all times to implement our approved fire and emergency evacuation plan.
Standard #:	22VAC40-73-680-D
Description:	Based on observation, staff interview and resident record review, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 6 contains a signed physician?s order, dated 03/26/2024, for bupropn hcl 150MG tablet take three tablets by mouth every day at 8:00AM for depression. 2. During medication cart audit on 07/23/2024, the licensing inspector (LI) noted that the medication card for the resident?s bupropn hcl 150MG contained three pills per blister/bubble. The LI and staff person 2 noted that the 8:00AM 07/23/2024 dose of bupropn hcl 150MG that had been popped out of the bubble pack/card by staff person 2 still contained one bupropn hcl pill indicating that the resident had only received two out of the three pills for the 07/23/2024 8:00AM dose. Interview with staff person 2 indicated that this was accurate and that they had only administered two tablets instead of three.
Plan of Correction:	ED/DON will in-service all RMA?s on the medication management plan.
Standard #:	22VAC40-73-870-A
Description:	Based on observation during a tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean. EVIDENCE: 1. The carpet outside the main doors at the threshold to the dining room near the bulletin board was noted to have various areas of staining. 2. The carpet on D cottage was noted to contain various areas of staining. 3. At approximately 9:14AM on 07/22/2024, the licensing inspector (LI) noted that the carpet on the bottom level of D cottage at the exit door was wet from the door to the bottom of the stairs. 4. The carpet in the hallway outside of the library and the A through D cottages was noted to have various areas of staining. 5. The front of the building was noted to contain various areas of chipping white paint.
Plan of Correction:	Facility will obtain a commercial grade carpet cleaner to assist with the removal of stains as needed to maintain stain-free carpets.
Standard #:	22VAC40-73-880-C
Description:	Based on observation, the facility failed to ensure temperatures in all areas used by residents shall not exceed 80 degrees Fahrenheit. EVIDENCE: Based on observation, the facility failed to ensure temperatures in all areas used by residents shall not exceed 80 degrees Fahrenheit. EVIDENCE: At approximately 2:52PM on 07/22/2024, it was noted by the licensing inspector (LI) and staff person 4 that the temperature in the common area on the second floor of E/F/G was 81.5 degrees Farhenhit and the hallway in the E cottage on the second floor was 83 degrees Farhenhit.
Plan of Correction:	ED or designee will ensure that two additional 10,000 BTU air conditioning units will be placed in the common area of E/F/G and in G hallway, respectively. Additionally, updated cooling towers have been ordered and will be installed upon arrival.
Standard #:	22VAC40-73-950-E
Description:	Based on documentation review and staff interview, the facility failed to ensure its semi-annual review on its emergency preparedness and response plan for all staff, residents, and volunteers shall be documented by signing and dating. EVIDENCE: The licensing inspector (LI) was provided documentation by staff persons 4 and 5 during on-site inspection that the facility had reviewed its emergency preparedness and response plan with residents on 03/14/2024; however, interview with staff persons 4 and 5 revealed that residents did not sign and date acknowledging that they had had the review. In addition, staff person 5 stated that staff person 1 had also reviewed the plan on 02/21/2024; however, staff person 5 was unable to produce evidence that staff person 1 had signed and dated that they had reviewed the plan.
Plan of Correction:	ED/BOM or designee will ensure that each resident, staff, and volunteers will have the emergency preparedness plan reviewed semi-annually and documented per state regulations requirements