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 9, 2024

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: 07/09/2024 Begin: 10:45am End: 3:10pm 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: 41 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 3 (plus 8 new employees) Number of interviews conducted with residents:2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. 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 #:	22VAC40-73-640-A
Description:	Based on observations made during the noon medication pass and the medication cart audit, the facility failed to implement their own plan for medication management. EVIDENCE: 1. The facility?s medication management plan (page 1, #4) addresses methods to ensure resident?s prescription and over the counter drugs ordered for the resident are filled and refilled in a timely manner to avoid missed doses. More specifically, 4.A of this plan states, ?All orders for medications, over the counter and supplements are promptly sent to the pharmacy. Pharmacy delivers daily to ensure all new orders for medications and existing medications are present as soon as possible to prevent missed doses. If for any reason the contracted pharmacy is not available to send the required medication, back up pharmacy will fill the physician/prescriber?s orders at that time to ensure no missed does.? 2. Resident # 1 is prescribed Pregabalin 200mg capsules, take one capsule by mouth three times daily for nerve pain per a physician?s order dated 06/10/2024 3. According to an interview with Staff #1 and per the July 2024 MAR, (Medication Administration Record) Resident #1 missed 10 doses of Pregabalin 200mg due to the medication not being available in the facility.
Plan of Correction:	ED/DON will ensure that all orders for medications are sent promptly to the pharmacy. Weekly audits will be conducted to ensure all medications are in the facility at all times. [sic]
Standard #:	22VAC40-73-680-M
Description:	Based on observations made during the medication cart audit, the facility failed to have all medications ordered for PRN (as needed) administration available for the specific resident. EVIDENCE: 1. Resident #1 has a physician?s order dated 06/24/2024, for Acetaminophen 325mg tablet, take two tablets by mouth every six hours as needed for pain or fever. 2. Staff #2 was not able to locate the Acetaminophen for Resident #1 on the medication cart. 3. During an interview with staff #1 and #2, both reported the medication was not available in the facility to the resident on the date of the inspection (7-09-2024).
Plan of Correction:	ED/DON will ensure that all orders for medications are sent promptly to the pharmacy. Weekly audits will be done. Back up pharmacy will be used if needed. [sic]
Standard #:	22VAC40-73-710-C
Description:	Based on resident record review, the facility failed to ensure a physician?s order for a restraint specified the condition, circumstances, and duration under which the restraint is to be used. EVIDENCE: 1. Resident #2 has a physician?s order dated 07/02/2024 for ?half siderails to hospital bed for safety and to aide in turning and repositioning self in bed? . This order does not address each of the above mentioned specifics according to the standards for licensed assisted living facilities.
Plan of Correction:	ED/DON will ensure when a physician writes an order pertaining to any DME, it will state the specified condition, circumstances, and duration under which the DME is to be used. [sic]