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 13, 2024 and Sept. 4, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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: 06/13/2024 10:30AM to 2:00PM and 09/04/2024 9:30AM to 1:45PM 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 06/13/2024 regarding allegations in the areas of: administration and administrative services & resident care and related services Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 6 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: resident care and related services A violation notice was issued; any violation(s) not related to the complaint 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 #:	22VAC40-73-300-B
Complaint related:	No
Description:	Based on staff interview and documentation review, the facility failed to ensure a method of written communication shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. EVIDENCE: 1. Resident 1 was admitted to the facility on 03/28/2024. During on-site inspection on 06/13/2024, the licensing inspector (LI) asked staff persons 1 and 2 to see the facility?s written communication from 03/28/2024 to 06/13/2024 that is utilized to keep direct care staff on all shifts informed of significant happenings or problems experienced by residents. 2. Staff person 2 provided the document ?Spring Oak MED AIDE TO MED AIDE 24-hour communication log? for 06/10-11/2024, 06/12-13/2024, and 06/13-14/2024 and informed the LI that they were not able to locate any additional communication logs for the cottage the resident resided on for the time period that was requested. 3. The record for resident 1 contains observation notes from 03/28/2024 to 06/13/2024 regarding resident 1; however, the observation notes are only documented by registered medication aides (RMAs) and nurses and interview with staff person 2 revealed that other direct care staff persons cannot document in these notes or utilize these notes because they do not have the ability to access them on the computer.
Plan of Correction:	Form has been adjusted to 24 hour communication log, aide and med techs will be educated on use of the log and have access to view it at all times.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission and shall include a description of identified needs and date identified based upon the (i) UAI; (ii) admission physical examination; (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (vi) other sources. EVIDENCE: 1. The record for resident 1 contains a uniform assessment instrument (UAI) that was completed by Collateral 1, dated 02/21/2024, that indicates on page one that Collateral 2 is the resident?s legal guardian and conservator. In addition, the record for the resident contains a document that is an order appointing guardian for the resident, Collateral 2, dated and signed by a judge on 01/05/2023. The document states that resident 1 is incapacitated and is incapacitated to such an extent that she is unable to care for herself or make medical decisions and that her illness significantly impairs her capacity to exercise judgement and/or self-control and that such condition is unlikely to improve in the foreseeable future. 2. The individualized service plan (ISP) for the resident, dated 04/26/2024, does not include information that the resident has a court appointed guardian.
Plan of Correction:	Resident files have been audited and will ensure ISPs accurately reflect Guardianship duties and responsibilities.
Standard #:	22VAC40-73-470-F
Complaint related:	Yes
Description:	Based on resident record review, the facility failed to ensure when the resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately, the circumstances involved and the medical attention received or refused shall be documented in the resident?s record, the date and time of occurrence, as well as the personnel involved shall be included in the documentation, the resident?s physician, if not already involved, next of kin, legal representative, designated contact person, case manager, and any responsible social agency, as appropriate, shall be notified as soon as possible but no later than 24 hours from the situation and action taken and, if applicable, the resident?s refusal of medical attention and if a resident refuses medical attention, the resident?s physician shall be notified immediately. EVIDENCE: 1. Facility staff note for resident 1 documented by staff person 3, dated 06/01/2024 at 10:30PM, states that the resident has been vomiting all evening, was asked several times if she wanted to be sent out, resident refused to be sent out and that the resident was given ginger ale. 2. The record for resident 1 does not contain documentation that the resident received medical attention from a licensed health care professional immediately (staff person 3 is not a licensed health care professional), does not contain documentation that the resident?s legal representative was notified of the incident of the resident?s refusal of medical attention or that the resident?s physician was notified of the resident?s refusal of medical attention.
Plan of Correction:	With ensure that the Director of Nursing or designee properly documents any abnormal medical concerns that are outside the residents baseline. The DON and or designee will assess the situation and properly make determination if outside medical attention is needed.