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: 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 07/11/2023 Begin: 10:3:0am End: 4:30pm 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 #:	22VAC40-73-100-C-1
Description:	Based on observations made during the medication cart audit, the facility failed to adhere to their infection control policy. EVIDENCE: 1. Resident #5?s glucometer was not labeled with his name on it. 2. Resident #6?s glucometer was found in a basket on another medication cart and the ?house? meter was located in resident #6?s bag which stores his glucometer.
Plan of Correction:	ED/DON will ensure all glucometers are labeled with residents names and stored in the medication cart designated for that resident. [sic]
Standard #:	22VAC40-73-190-C
Description:	Based on record review, the facility failed to provide written documentation of duties and responsibilities to two staff members prior to being placed in charge. EVIDENCE: 1. Staff #1 and staff #2 both began employment on 02/08/2023. 2. According to staff #3 both staff #s 1 and #3 serve as the person in charge from time to time at the facility. 3. Staff #1 and staff #3?s files did not contain documentation of duties prior to being placed in charge.
Plan of Correction:	ED/BOM will provide going forward each staff member that?s in charge with written documentation of such duties and responsibilities. [sic]
Standard #:	22VAC40-73-230-B
Description:	Based on observations made during the tour of the building and interviews with staff, the facility failed to have a written agreement between themselves and any resident who performs staff duties. EVIDENCE: 1. Resident #5 was performing the scheduled activity for the morning on the day of the inspection by leading a bible lesson. 2. In the evening, resident #8 was performing the scheduled activity on the day of inspection, he was calling out bingo numbers. 3. According to staff #3, neither resident had a written agreement with the facility to perform those staff duties.
Plan of Correction:	ED has a written agreement on file for each resident that agrees, and or volunteers at the facility. The agreement includes specified duties, hours worked, and compensation. [sic]
Standard #:	22VAC40-73-310-H
Description:	Based on review of resident records, the facility failed to deny admission to an individual with a prohibitive condition. EVIDENCE: 1. Resident #1?s physical was completed by a physician on 05/03/2021. On page five of the physical ?yes? is checked beside of psychotropic medications without appropriate diagnosis and treatment plan, This is a prohibitive condition.
Plan of Correction:	ED/DON will ensure no resident will be admitted to the facility with a prohibited condition without an appropriate treatment plan. [sic]
Standard #:	22VAC40-73-490-C
Description:	Based on resident record review, the facility failed to have a qualified health care professional (at a minimum a registered nurse)to complete the required health care oversight for restrained residents. EVIDENCE: 1. Residents #4 and #9 have half bedrails which are viewed as a restraint due to the documentation by a physician of their cognitive status. 2. The last healthcare oversight was completed on 06/30/2023 and was completed by two LPNs (License practical nurses).
Plan of Correction:	ED/DON will ensure that when and if the facility uses a restraint that the health care professional that does oversight is a Registered nurse and does oversight at least every three months. [sic]
Standard #:	22VAC40-73-520-I
Description:	Based on observations made during the tour of the building, the facility failed to follow the written schedule of activities which was posted for July 2023. EVIDENCE: 1. On 07/11/2023 at 10:00am the activities calendar listed ?sing-a-long? as the scheduled activity. 2. At 10:15 am this activity was not taking place.
Plan of Correction:	ED/Activity?s Director will ensure that Activities are conducted as planned. If an activity is rescheduled or changed it will be noted on the Calendar. [sic]
Standard #:	22VAC40-73-680-B
Description:	Based on observations made during the medication cart audit, the facility failed to ensure each individual medication properly labeled from the pharmacy. EVIDENCE: 1. On 05/31/2023 Resident #7 was prescribed Tresiba Flextouch 100units, inject 24 units at bedtime and Victoza18mg, inject 0.6 daily. 2. Neither of the above mentioned medications had the directions on the packaging of the medication.
Plan of Correction:	ED/DON will ensure each resident?s medication is properly labeled from the pharmacy with directions on the packaging label. [sic]
Standard #:	22VAC40-73-680-D
Description:	Based on observations made during the medication pass, the facility failed to administer medications in accordance with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. Victoza, a non-insulin injection was being administered by a registered medication aide.
Plan of Correction:	ED and DON will ensure that no non-insulin injection will be administer by an RMA or administer at the facility [sic]
Standard #:	22VAC40-73-680-G
Description:	Based on observations made during the medication cart audit, the facility failed to have any over-the-counter medication in the original container, labeled with the resident?s name or in a pharmacy-issued container until administered. EVIDENCE: 1. Skintegrity wound cleanser was found on the medication cart with no name. 2. Staff #2 stated Hospice brought it in .
Plan of Correction:	ED/DON will ensure all medications are labeled with resident?s name and stored in a pharmacy issued container. DON will conduct weekly cart audits. [sic]
Standard #:	22VAC40-73-680-I
Description:	Based on observations made during the medication pass, the facility failed have all required information documented on the MAR (Medication administration Record) EVIDENCE: 1. Resident #3 has a physician?s order for Ensure three time a day with meals, this was not listed on the MAR. 2. Resident #4 is prescribed Lorazepam 1mg daily by mouth. The MAR for 07/11/2023 did not document the medication was administered to resident #4.
Plan of Correction:	ED/DON will ensure that physicians orders are transcribed to the Mar by conducting a weekly audit on all new orders, and will be keeping a pending order binder to ensure all orders are followed. [sic]
Standard #:	22VAC40-73-680-M
Description:	Based on observations made during the medication pass, the facility failed to have medications ordered for PRN (as needed) administration available and properly labeled for the specific resident and properly stored at the facility. EIDENCE: 1. Resident #4 is prescribed one can of Ensure three times daily as needed. This medication was not available to the resident. 2. Resident #7 is prescribed Hydralazine 10mg every six hours by mouth as needed. This medication was not available to the resident. 3. Resident #2 is prescribed Cyclosporin .05%, instill one drop into both eyes twice daily as needed for dry eyes. This medication was not available to the resident.
Plan of Correction:	ED/DON will ensure all medications are labeled with the resident?s name and properly stored, and ready for administration. DON will conduct monthly cart audits. [sic]
Standard #:	22VAC40-73-710-C
Description:	Based on observations made during the tour of the building and resident records, the facility failed to have a physician?s order when restraints are being used. EVIDENCE: 1. Resident #4 was admitted to the facility on 02/17/2023. Dementia and altered mental status were listed on the 02/10/2023 physical for resident #4. The 03/17/2023 UAI (Uniform Assessment Instrument) for resident #4 documents disorientation to place and time. 2. Resident #9 was admitted to the facility on 05/12/2021. Alzheimer?s dementia were documented on the 05/03/2021 physical for resident #4. The 01/05/2023 UAI (Uniform Assessment Instrument) for resident #4 documents wandering passive at east weekly or more and disoriented to all spheres at all times. 3. Residents #4 and #9 was observed to have half rails on their beds. No physician?s orders were in the files for resident #4 or #9 to use the half rails. 4. Residents #4 and #9 were interviewed while in bed and neither resident could tell the LI or show the LI how to use the bedrail or what the bedrail was for, making this a restraint.
Plan of Correction:	ED/DON will ensure that any resident that has a restraint or any DME device that can be use as a restraint will have a physician?s written order the specifies the condition, circumstance, and the duration under the restraint is to be use. [sic]
Standard #:	22VAC40-73-710-D
Description:	Based on review of resident records and staff interview, the facility failed to document the usage, outcome, and checks on any residents when restraints are in use. EVIDENCE: 1. According to staff #3 there was no record of restraint usage, outcomes of restraint usage and no documentation of 30-minute checks for residents #4 and #9.
Plan of Correction:	ED/DON will ensure that floor staff document the usage, outcome, and checks on any resident with restraints by creating and auditing log for residents that have a restraint. [sic]
Standard #:	22VAC40-73-860-G
Description:	Based on observations made during the tour of the building, the facility failed to maintain hot water taps available to residents within a range of 105 degrees to 120 degrees Fahrenheit. EVIDENCE: 1. The Licensing Inspector measured water temperature from the bathroom sink in room #9 and room #2 2. The hot water handle was turned on and allowed to run for 120 seconds. A thermometer was placed in the running water for 120 seconds. 3. The thermometer reading reached 71.4 degrees in room #9 and 75.3 degrees in room #2.
Plan of Correction:	ED/Maintenance will ensure Hot water stays within a range of 105 F to 120 F. Weekly checks will be conducted by ED/Maintenance Director to ensure compliance. [sic]
Standard #:	22VAC40-73-860-I
Description:	Based on observations made during the tour of the building, the facility failed to keep cleaning supplies and other hazardous materials in a locked area. EVIDENCE: 1. Room #37 located downstairs was found to be unlocked and contained power tools and ceiling paint. 2. Outside of room #36 an unsecured, unlocked cart with furniture polish was found in the hall.
Plan of Correction:	ED/Maintenance will ensure any hazardous materials and cleaning supplies are in a locked area and out- of- sight away from residents with cognitive impairment. [sic]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during the tour of the building, the facility failed to have the interior and exterior of all buildings maintained in good repair and kept clean and free of rubbish. EVIDENCE: 1. The floor area downstairs was very sticky where the carpet had been removed and not replaced yet. Staff stated carpet was removed at least two weeks ago. 2. The exterior of the building was found to have an old bed frame propped up on the back corner. 3. The floor area outside of room #36 was sticky outside in the hall area.
Plan of Correction:	ED/Maintenance will ensure the interior is in good repair. The flooring downstairs has been replaced. All old furnishings and fixtures are monitored during the daily walk through to ensure there is nothing that needs to be removed. [sic]
Standard #:	22VAC40-73-870-F
Description:	Based on observations made during the tour of the building, the facility failed to have nonslip surfaces on ramps, stairways, and steps inside and outside of the building. EVIDENCE: 1. The nonskid surfaces on the ramp outside of room #30 are missing. 2. The ramp near the deck off of the dining room is missing the nonskid strips.
Plan of Correction:	ED/Maintenance have and will replace non slid strips on all outside steps, stairwell, and ramps, this will be monitored as needed. [sic]
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to obtain the criminal history record report on or prior to the 30th day of employment for three employees. EVIDENCE: 1. Staff #4 began employment on 05/09/2023, on 07/11/2023 the results of the background check had not been received. 2. Staff #5 began employment on 05/15/2023, on 07/11/2023 the results of the background check had not been received. 3. Staff #6 began employment on 04/18/2023, on 07/11/2023 the results of the background check had not been received.
Plan of Correction:	ED/BOM will ensure that all staff members will have a criminal history record within their 30th day of employment [sic]