VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Spring Oak Warrenton
239 Alexandria Pike
Warrenton, VA 20186
(540) 347-6000

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: June 24, 2024

Complaint Related: Yes

Areas Reviewed:

Administration and Administrative Services Personnel Staffing and Supervision Resident Care and Related Services Resident Accommodations and Related Provisions

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: 06/24/2024 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: 14 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing Inspector observed residents eating breakfast and lunch. Additional Comments/Discussion: 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 and Resident Accommodations and Related Provisions. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-520-I
Complaint related:	No
Description:	Based on observation, review of activity schedule and staff interview, the facility failed to offer at least one hour of activities each day. Evidence: 1. No activity programs were observed to be offered on the date inspection on 6/24/2024. 2. Staff 2 stated the reason activity programs did not occur was the Activities Director was needed to help in the kitchen.
Plan of Correction:	ED/or designee will ensure that activities that are posted in the community will be performed as posted. In the event that an activity changes, ED or designee will be responsible to change it on the activity calendar to reflect corrections.
Standard #:	22VAC40-73-680-C
Complaint related:	No
Description:	Based on resident record review, the facility failed to administer medication not later than one after the facility?s standard dosing schedule. Evidence: 1. Resident 1?s May 2024 Medication Administration Record indicates the following medication were administered late: Eliquis 5mg tablet scheduled for 8:00am was administered late on 5/3/2024 at 9:03am, 5/4/2024 at 9:28am, 5/10/2024 at 9:38am, 5/15/2024 at 9:14am, 5/21/2024 at 9:21am and 5/25/2024 at 9:07am, Bupropn HCL tab 150mg XL scheduled for 8:00am was administered late on 5/3/2024 at 9:02am, 5/4/2024 at 9:28am, 5/10/2024 at 9:38am, 5/15/2024 at 9:15am, 5/21/2024 at 9:20am and 5/25/2024 at 9:07am, Duloxetine 30mg capsule scheduled for 8:00am was administered late on 5/3/2024 at 9:03am, 5/4/2024 at 9:28am, 5/10/2024 at 9:38am, 5/15/2024 at 9:14am, 5/21/2024 at 9:20am and 5/25/2024 at 9:07am, Valsartan 320mg tabs scheduled for 8:00am was administered late on 5/3/2024 at 9:04am, 5/4/2024 at 9:30am, 5/10/2024 at 9:39am, 5/15/2024 at 9:14am, 5/21/2024 at 9:21am and 5/25/2024 at 9:07am, Antacid 500mg assorted flav scheduled for 8:00am was administered late on 5/3/2024 at 9:03am, 5/4/2024 at 9:27am, 5/10/2024 at 9:38am, Lidocaine 4% patch (OTC) scheduled for 8:00am was administered at 9:27am, Amlodipine tab 10mg scheduled for 8:00am was administered late on 5/10/2024 at 9:38am, and on 5/15/2024 at 9:15am. 2. Resident 2?s May 2024 Medication Administration Record indicates the following medication were administered late: Levothyroxine Sod 50mcg tab scheduled for 5:30eam was administered on 5/10/2024 at 6:36am, 5/11/2024 at 6:33am 5/12/2024 at 6:33am and on 5/15/2024 at 6:37am, Mucus Relief tab 600mg ER scheduled for 8:00am was administered on 5/10/2024 at 9:57am, Allopurinol 100mg tablet scheduled for 8:00am was administered on 5/18/2024 at 9:12am, Alprazolam tab 0.25mg scheduled for 8:00am was administered on 5/18/2024 at 9:09am, Eliquis 5mg tablet scheduled for 8:00am was administered on 5/18/2024 at 9:11am. The following medications were scheduled on 5/18/2024 at 8:00am: Bisoprolol Fum 10mg tablet administered at 9:11am, Furosemide 20mg tablet administered at 9:12am, Myrbetriq 25mg tablet 7.5mg administered at 9:12am, Potassium Chlor 20meq tablet administered at 9:26am, Prednison 5mg tablet administered at 9:26am, Azithromycin 500mg tablet administered at 9:11am and Fluticasone Prop 50mcg/ACT SPR administered at 9:11am.
Plan of Correction:	ED/DON will review MAR report for the previous day during stand up to ensure accuracy and all medications are administered in the timeframe of 1 hour before and/or 1 hour after. ED/DON will sign off on the MAR report daily and keep a signed copy in a binder in the ED?s office and kept for records. All RMA?s will be in-serviced on the Med Management policy.