VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Spring Oak Christiansburg
1140 West Main Street
Christiansburg, VA 24068
(732) 719-8684

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: April 26, 2023

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 GROUND ? 22VAC40-73 EMERGENCY PREPAREDNESS

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: 04/26/2023 Begin: 10:30am End: 3:54pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Crystal B. Henson Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to document all information required by standards on the resident personal and social data information sheet. EVIDENCE: 1. Page two of the personal/social data was left blank for strengths and problems under current behavioral and social functioning for resident #1, #2, #3, #, and #8 2. Page two of the personal/social data was left blank for the following areas: strengths and problems under current behavioral and social functioning; previous mental health or intellectual disability; and substance abuse history for resident #5
Plan of Correction:	ED and DON will ensure that all standards on the resident personal and social data 2+information sheet are recorded. ED, and DON will audit each resident?s chart to ensure strengths, problems, under current behaviors, and social functioning are filled out. [sic]
Standard #:	22VAC40-73-610-B
Description:	Based on a tour of the building and interview with staff, the facility failed to ensure any menu substitutions were recorded on the posted menu. EVIDENCE: 1. The lunch menu dated 04/26/2023 listed herbed pot roast for the entree. 2. The LI observed chipped beef being served as the lunch entree on 04/26/2023. 3. Staff # 4 confirmed chipped beef was substituted for the pot roast. 4. The substitution was not recorded on the posted menu.
Plan of Correction:	ED, Dietary Manager, and Cook will ensure any menu substitution will be recorded on the posted menu. When an item is substituted on the menu it will be changed on the menu immediately. [sic]
Standard #:	22VAC40-73-680-H
Description:	Based on a review of medication administration records (MARs) and interviews with staff, the facility failed to document on the MAR all medications administered to residents, including over-the-counter medications and dietary supplements, for four residents. EVIDENCE: 1. There were no staff initials on the MAR for resident # 9 indicating the following medications were given on 04/08/2023: Atorvastatin Calcium 40mg tablet, 4pm and 8pm doses, and Hydralazine Hydrochloride 25mg tablet, 4pm dose. 2. There were no staff initials on the MAR for resident # 10 indicating the following medications were given on 04/17/2023: Gabapentin 100mg cap and Lisinopril 40mg tab, 6am doses. 3. There were no staff initials on the MAR for resident # 11 indicating the following medication was given on 04/02/2023: Humalog 100U/ML Vial/15 units, 4:30pm dose. There were no staff initials on the MAR for the same resident indicating the following medications were given on 04/08/2023: Acetaminophen 500mg Tablet and Lantus 100U/ML Vial, 45 units, 8pm doses, Humalog 100U/ML Vial, 15 units, 4:30pm dose, and Lubricant 0.6% Opth Eye Drops, 5pm dose. 4. There were no staff initials on the MAR for resident # 13 indicating the following medications were given on 04/08/2023: Diltiazem 30MG tablet, 4pm dose, and Ketorolac 0.5% Opth Sol 5ML, 5pm dose. There were no staff initials on the MAR for the same resident indicating the following medication was given on 04/22/2023: Latanoprost 0.005% Op Sol, 8pm dose.
Plan of Correction:	ED, DON, and RMA will ensure that the MAR is filled out at the time the medication is given. ED,DON, and RMA will audit the MAR each shift to ensure proper documentation on all medication given. [sic]
Standard #:	22VAC40-73-870-A
Description:	Based on 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 and free of rubbish. EVIDENCE: 1. The floor of the air handler closet between resident rooms #17 and #19 was covered in dirt and dust. There also appeared to be a clump of used tissue and a disposable plastic cup in the floor of the same closet. 2. There were several clumps of dirt and dust observed between the horizontal slats in the top portion of the door to the air handler closet between resident rooms #17 and #19. 3. There was dust observed between the slats in the air filter grille located in the lower portion of the door to the air handler closet between resident rooms #6 and #8. 4. Several dark spots/stains were observed on the carpet of the stairs leading to the basement, and on the carpet in the basement hallway.
Plan of Correction:	ED, Maintenance, and housekeeping staff will ensure that air handler closet will be free of dirt and dust by cleaning inside of closet monthly. Housekeeping will dust in between horizontal slats weekly to ensure no dirt and dust build up. 05/01/2023 [sic] Spring Oak Management, ED, and Maintenance will Deep clean, and or replace carpet leading to the basement, and downstairs. 07/31/2023 [sic]