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: Aug. 10, 2023

Complaint Related: Yes

Areas Reviewed:

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: 08/10/2023 Begin: 2:35pm End: 3:20pm 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: did not collect information The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 17 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 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 the allegations of non-compliance with standard(s) or law, and violation(s) were 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 Crystal B. Henson Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-B
Complaint related:	Yes
Description:	Based on collateral and staff interview, facility self-report, and a complaint received by the Department, the facility failed to keep medications in their pharmacy issued container, with the prescription label or directions attached, until administered to the resident. EVIDNECE: 1. The Department received a complaint on07/14/2023 regarding staff #1?s medication administration practices. 2. Per a telephone conversation on 07/14/2023 with collateral #1 she reports while she was in the facility on 05/13/2023 at approximately 5:30pm she witnessed staff #1open the medication cart to administer the evening medications and she then observed numerous medications which were pre-poured sitting in clear souffle cups inside the medication cart. Collateral #1 states she immediately went to speak with staff #2 regarding her concerns. 3. The Licensing Inspector received a written report from the facility via e-mail on 07/17/2023 regarding staff #1. The e-mail stated staff #1 ?was observed by the ombudsman (name) pre-pulling medications from her cart. ED[Executive Director] was able to verify that there was pre-pulled medication left in the cart.? 4. LI interviewed staff #2 on 08/10/2023 at the facility regarding the complaint/report. Staff #2 stated she was notified by collateral #1 that she had observed staff #1 open the medication cart to administer evening medications and collateral #1 saw numerous pre-poured medications. During this same interview with staff #2 she also stated she immediately went to staff #1 and asked her to open the medication cart. When staff #1 opened the medication cart, staff #2 witnessed numerous pre-poured medications which were in clear souffle cups labeled with the names of residents #1 ? #17 and their room numbers. 5. According to an interview with staff #2, staff #1 was asked to leave the facility until further notice and all pre-poured medications were wasted by staff #2. 6. Staff #3 was then tasked with administering all the evening medications that had not been documented on the July 13, 2023, MAR for 5:00pm and later. 7. Staff #2 stated residents #1 - #17 did not miss their dose of evening/night-time medication for July 13, 2023.
Plan of Correction:	ED/DON will ensure all current medication aides are education on medication policy and procedure. All medication aides will receive medication refresher. Staff #1 has been terminated from the facility and reported to nursing board. [sic]