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: July 11, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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:07/11/2023 Begin: 9:30am End: 10:30am 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 06/26/2023 regarding allegations in the area(s) of: resident/staff interaction and medication administration Number of residents present at the facility at the beginning of the inspection: 55 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: 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 allegation(s); area(s) of non-compliance with standard(s) or law: A violation notice was issued; any violation(s) not related to the complaint(s) 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. he 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 #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on staff and collateral interviews, the facility failed to administer medications consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. According to interviews conducted on 07/11/2023 with staff #2 and #3; resident #1 does not have self-administer orders for any of the medications she is prescribed. 2. Staff #2 and#3 stated the facility administers all prescribed medications to resident #1 daily. 3. Resident #1 receives the following medications at noon according to the June 2023 MAR (Medication Administration Record) and per interview with staff #2: Bupropion SR 150mg, take 1 tablet daily for depression; Citalopram 20mg, take 1.5 tablets daily for depression; Jardiance 10mg, take 1 daily for diabetes; Letrozole 2.5mg, take 1 daily for breast cancer; Losartan 50mg, take 1 daily for hypertension; and Clonazepam 0.5mg, take 1 table twice daily for anxiety. 4. Collateral #1 was sitting with resident #1 at a table located in the dining area at approximately 12:05pm on 06/26/2023. Staff #1 brought a white souffle cup containing resident #1?s noon medications and a small cup of water to the dining table where collateral #1 and resident #1 were seated. Staff #1 placed the souffle cup and the cup of water on the table and stepped away. At this time, ED/DON will ensure Register Medication Aides are trained on facility?s medication management plan. ED/DON will ensure that each Register Medication Aide will receive Medication aide refresher course and education. ED/DON will ensure Register Medication Aide who are responsible for administering medication are being supervised by doing periodic direct observation of medication administration. 07/31/2023 Colateral #1 requested staff #2 to observe the contents of the souffle cup. Per staff #2 interview it was confirmed resident #1?s noon medications were in the white souffle cup.
Plan of Correction:	ED/DON will ensure Register Medication Aides are trained on facility?s medication management plan. ED/DON will ensure that each Register Medication Aide will receive Medication aide refresher course and education. ED/DON will ensure Register Medication Aide who are responsible for administering medication are being supervised by doing periodic direct observation of medication administration. [sic]