Virginia DSS · Assisted Living Facility

Spring Oak Tri-Cities LLC

📍 550 and 590 Flank Road, Petersburg, VA, 23805

ID 44545Two Year licenseActive
11
Inspections
On record
5
With violations
Visits that cited something
6
Clean visits
Nothing cited
28
Violations cited
Individual findings
25
Standards cited
Distinct rules
4
Complaint visits
Prompted by a complaint

Spring Oak Tri-Cities LLC was inspected 11 times between December 2, 2020 and March 24, 2026 by the Virginia Department of Social Services. 5 of those visits ended with violations cited and 6 with none. Across that history VDSS cited 28 violations under 25 distinct standards. 4 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 9 of these 11 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
12/31/2026
Administrator
Sharon Jones
Licensing inspector
Tamara Watkins
Inspector phone
(804) 840-3710
Approved for
Non-Ambulatory · Assisted Living · Special Care Unit

Inspection History

11

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

March 24, 2026Inspection2 violations
Inspection dates
03/24/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1- (37) REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2- (1) GENERAL PROVISIONS63.2- (16) PROTECTION OF ADULTS AND REPORTING63.2- (17) LICENSURE AND REGISTRATION PROCEDURES63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/24/2026 11:45a – 2:15p 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: 47 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Medication Administration, lunch, resident accommodations, resident care, required postings Additional Comments/Discussion: An exit meeting was 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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 Tamara Watkins, Licensing Inspector at (804) 840-3710 or by email at tamara.g.watkins@dss.virginia.gov Violation Notice Issued: Yes By signature, the facility representative acknowledges receipt of the inspection findings, including the Inspection
Violations
22VAC40-73-480-E
Based on a review of resident records the facility did not ensure that the prescriber orders, services provided, evaluations of progress, and other pertinent information regarding the rehabilitative services shall be recorded in the resident’s record.
Evidence
  1. The results of a 12/30/25 recommended occupational and physical therapy consult for resident #2 were not recorded in the resident’s record.
Plan of correction
Notes were requested fromPT and recorded in chart and service plan.
22VAC40-73-940-A
Based on a review of facility inspection reports, the facility failed to ensure compliance with the Virginia Statewide Fire Prevention Code with an annual inspection by the appropriate fire official.
Evidence
  1. The fire inspection provided for review was dated 1/30/2024.
Plan of correction
An updated fire inspection and report was completed on 3.26.2026.
October 3, 2025Complaint survey0 violations
Inspection dates
10/03/2025
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: 10/3/2025 1:25p – 2:00p The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of interviews conducted with staff: 1 Observation of PPE supplies. Additional Comments/Discussion: The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Tamara Watkins, Licensing Inspector at 804-840-3710 or by email at tamara.g.watkins@dss.virginia.gov Violation Notice Issued: No
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 3, 2025Complaint survey0 violations
Inspection dates
10/03/2025
Areas reviewed
&63.2 -1808
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: 10/3/2025 1:15p – 2:00p 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: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Additional Comments/Discussion: The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Tamara Watkins, Licensing Inspector at 804-840-3710 or by email at tamara.g.watkins@dss.virginia.gov Violation Notice Issued: No
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 4, 2024Inspection0 violations
Inspection dates
12/04/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
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: 12/4/2024 12:00 – 2:30p 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: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Staffing and Housekeeping schedules; Health Care and Dietary Oversight; Activities; Medication Administration and Medication cart. Additional Comments/Discussion: The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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 Tamara Watkins, Licensing Inspector at (804) 662-7422 or by email at tamara.g.watkins@dss.virginia.gov Violation Notice Issued: No
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 8, 2024Inspection0 violations
Inspection dates
04/08/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
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: 04/08/2024 12:00p – 2:45p 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 no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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 Tamara Watkins, Licensing Inspector at (804) 662-7422 or by email at tamara.g.watkins@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 21, 2022Complaint survey0 violations
Inspection dates
09/21/2022
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: Complaint The licensing inspector was on-site at the facility for each day of the inspection: Date(s) of inspection 9/21/2022 11:00a -5:00p. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was Type of inspection: Complaint The licensing inspector was on-site at the facility for each day of the inspection: Date(s) of inspection 9/21/2022 11:00a -5:00p. 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 (8/11/2022) regarding allegations in the area(s) of: Staffing and Supervision; Resident Care and Related Services; Resident Accommodations and Related Provisions Number of residents present at the facility at the beginning of the inspection: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: Resident bedrooms, common areas, lunch, staff resident interactions. Additional Comments/Discussion: The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Tamara Watkins, Licensing Inspector at (804) 662-7422 or by email at tamara.g.watkins@dss.virginia.gov Violation Notice Issued: No
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 21, 2022Inspection6 violations
Inspection dates
09/21/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal Date(s) of inspection 9/21/2022 from 11:00a -5:00p. The licensing inspector was on-site at the facility for each day of the inspection: 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: 34 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: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: Resident bedrooms, common areas, lunch, staff resident interactions. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the renewal inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The applicant has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to maintain future compliance with applicable standard(s) or law. If the applicant 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 should the facility be issued a license to operate. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Tamara Watkins, Licensing Inspector at (804) 662-7422 or by email at tamara.g.watkins@dss.virginia.gov Violation Notice Issued: Yes
Violations
22VAC40-73-440-A
Based on a review of resident records the facility failed to complete an annual uniform assessment instrument for all residents.
Evidence
  1. Resident #1 was admitted to the facility on 4/8/2019 the last UAI was completed on 4/8/2021; Resident #6 was admitted to the facility on 7/31/2020 the last UAI was completed on 7/16/2021.
Plan of correction
Not published by VDSS.
22VAC40-73-1100-A
Based on a review of resident records the facility failed to obtain approval prior to placement of a resident in a safe secure environment.
Evidence
  1. Written approval for placement in the secure unit was not maintained in the resident record for resident #1.
Plan of correction
Not published by VDSS.
22VAC40-73-250-D
Based on a review of staff records the facility failed to maintain and include in the staff record for each person an initial tuberculosis risk assessment.
Evidence
  1. There was no initial tuberculosis risk assessment maintained in the staff record for Staff #3,4,5.
Plan of correction
Not published by VDSS.
22VAC40-73-550-G
Based on a review of resident and staff records the facility failed to review annually with each resident or staff person the rights and responsibilities of residents in an assisted living facility.
Evidence
  1. The last rights review documented for Resident#1 is 7/20/2020; Resident #3 is 7/12/2020; Resident #6 is 7/31/2020. The last rights review documented for Staff #1 is dated 2019. No rights review was documented for Staff# 2,3,4,5.
Plan of correction
Not published by VDSS.
22VAC40-73-120-A
Based on a review of staff records the facility failed to ensure that orientation and training occurred within seven days of employment.
Evidence
  1. No orientation was maintained in the staff record for Staff #2 employed on 8/23/22; Staff #3 employed 9/4/22; and Staff #4 employed 8/24/2022.
Plan of correction
Not published by VDSS.
22VAC40-73-450-F
Based on a review of resident records the facility failed to ensure that individualized service plans are reviewed and updated every 12 months.
Evidence
  1. Resident #1 was admitted to the facility on 4/8/2019 the last ISP in the resident record is dated 4/8/2021. Resident #6 was admitted to the facility on 7/31/20 the last ISP in the resident record is dated 7/16/2021.
Plan of correction
Not published by VDSS.
October 21, 2021Inspection0 violations
Inspection dates
10/21/2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
A renewal) inspection was initiated on 10/21/2021 and concluded on 10/28/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was (27). The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed (4) resident records, (3) staff records, activities calendar, staff schedules, medication administration records, health care oversight, fire and health inspection reports, etc.) submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 10/28/2021. An exit interview was conducted with the Administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 27, 2021Inspection3 violations
Inspection dates
08/27/2021
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS
Comments
A non-mandated focused monitoring inspection was initiated on 8/24/2021 and concluded on 8/27/2021. An intensive plan of correction and a risk profile follow-up was conducted by the department in the areas of Staffing and Supervision, Resident Care and Related Services and Building and Grounds. The administrator was contacted by telephone to conduct the inspection. The licensing inspector emailed the administrator a list of documentation required to complete the inspection. The licensing inspector conducted an on-site observation at the facility on 8/27/2021. An exit interview was conducted with (the Administrator and Director of Nursing) on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-680-M
Based on an audit of the medication cart PRN medications were not available.
Evidence
  1. Resident #1 The PRN medications Acetaminophen 325 mg two (2) tablets and Loratadine (Claritin) (1) 10 mg tablet listed on the August 2021 MAR were not available in the medication cart. Resident #2 The PRN medication Nitroglycerin 0.4 one (1) tablet to be given sublingually listed on the August 2021 MAR was not available in the medication cart.
Plan of correction
PRN Tylenol and Claritin were immediately reordered for resident #1. PRN Nitroglycerin was immediately reordered for resident #2. All medications were delivered 8/28/21 and remain available for PRN use. Resident #1 and Resident #2 had no adverse effects as they had not requested nor indicated use for these PRN medications during this time. DON contacted NP and Pharmacy to verify all fax numbers being utilized for refill requests, an error was identified and immediately corrected. 2) DON or pharmacy representative will conduct an in-service for all Medication Aides to ensure they reord any medications that need to be reordered on the 24-hour communication log. DON also implemented new policy to ensure pharmacy includes number of refills on all medication labels. 3) DON or designee will audit medication carts daily x 5 days, then weejkly x4 weeks, then monthly x2 months to ensure that all PRN medications are available, properly labeled for the speciic resident and properly stored. 4) Expected Date of Completion 9/10/21.
22VAC40-73-640-D
Based on an on-site observation the facility failed to maintain a current pharmacy reference book, drug guide or medication handbook available to staff who administer medications.
Evidence
  1. Staff #2 located a 2016 Pill Book in the medication cart however it was dated 2016.
Plan of correction
1) Facility immediatdely ordered (2) copies of 2022 Drug Reference guide from out pharmacy partner. Guides delivered 8/28/21 and placed in carts accordingly. 2) As a redundancy, Spring Oak ordered additional copies of Drug guides that were delivered on 8/29/21 to retain as a back-up copy. 3) Pharmacy representative will in-service all medication aides on availability and use of current drug resource guide located on the med carts in conjunction with our Electronic Medical Rcord Drug guide. DON or designee will audit medication carts daily x5 days, weekly x4 weeks then monthly times 2 months to ensure Drug Reference guides are available and staff are aware of how to utilized them in conjunction with our Electronic Medical Record Drug Guide. Expected Date of Completion: 9-10-21.
22VAC40-73-660-A-2
Based on an on-site audit of the medication cart controlled substances were not kept in a locked container within the locked cart.
Evidence
  1. Upon review of the medication cart the locked section of the cart designated for narcotics (Schedule II drugs) was broken. Narcotic medications are stored in the medication cart but are unable to be double locked. Staff #2 stated the pharmacy (Family Care) had been notified about this but responded that due to the pandemic they were unable to come out to perform a medication cart audit. The facility recently contacted them again and is waiting for them to respond.
Plan of correction
1) Pharmacy contacted 8/28/21 to request narcotic box for medication cart. 2) Pharmacy delivered new narcotic box for cart on 9/3/21. DON or designee will conduct an inservice for all medication aides to ensure they are aware of 22VAC40-73-(6)-660-A-2 standard and proper procedures for new narcotic drug box being implemented on medication cart. 3) DON or designee will audit cart and narcotic boxes daily x 5 days, then weekly x 4 weeks, then monthly x 2 months to ensure that schedule II medications are appropriately double locked. 4) Expected Date of Completion 9/10/21.
May 25, 2021Inspection6 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 5/25/2021 and concluded on 6/25/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 27. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed (5) resident records, (2) staff records, staff schedules, medication administration records, individualized service plans, fire drills, health care oversight, etc.) submitted by the facility to ensure documentation was complete. This inspection also includes a follow up on previously cited high risk violations and an intensive plan of correction. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-1130-A
Based on a review of staff schedules and accompanying documentation the facility failed to ensure that there were at least two direct care staff members awake on duty at all times in the special care unit who were responsible for the care and supervision of the residents.
Evidence
  1. At the time of the inspection there were (10) residents present in the memory care unit. The evidence reflects the dates and time the memory care unit was not staffed with two direct care staff members on the 7am -3pm and 3pm - 11pm shifts. Based on a cross reference of the Monthly Work Schedules submitted for April 18 2021 - May 25, 2021, the daily Person- In-Charge Report from April 18, 2021 - May 25, 2021 and the Timecard Reports dated April 18, 2021- April 30, 2021 and May 1, 2021 - May 25, 2021 for each staff member:
  2. On April 24, 25, & 27, 2021 and May 2, 8, 9, 11 & 21, 2021 there was one staff or no staff scheduled to work on the memory care unit during the 7am - 3pm shift.
  3. On April 18-23 & 26-30, 2021 there was one staff or no staff scheduled to work on the memory care unit during the 3pm -11pm shift.
  4. On May 1-11, 12-20 & 24,25 2021 there was one staff or no staff scheduled to work on the memory care unit during the 3pm -11pm shift.
Plan of correction
Not published by VDSS.
22VAC40-73-1130-C
Based on a review of staff schedules and accompanying documentation during the night hours the facility failed to ensure that there were at least two direct care staff members awake and on duty at all times in the special care unit who were responsible for the care and supervision of the residents.
Evidence
  1. At the time of the inspection there were (10) residents present in the memory care unit. The evidence reflects the dates and times the memory care unit was not staffed with two direct care staff members during the night hours. Based on a cross reference of the Monthly Work Schedules submitted for April 18 2021 - May 25, 2021, the daily Person- In-Charge Reports from April 18, 2021 - May 25, 2021 and the Timecard Reports dated April 18, 2021- April 30, 2021 and May 1, 2021 - May 25, 2021 for each staff member:
  2. On April 18, 19, 22-25, 27, 28 &30, 2021, there was one staff or no staff scheduled to work on the memory care unit during the 11pm -7am shift.
  3. On May 1-2 & 4-24, 2021 there was one staff or no staff scheduled to work on the memory care unit during the 11pm -7am shift. During the entire month of May, 2021 there were only two days when two staff were scheduled to work on the memory care unit from 11pm -7am.
Plan of correction
Not published by VDSS.
22VAC40-73-290-A
Based on a review of staff schedules and an interview with staff, the facility failed to maintain a written work schedule that includes the names and job classifications of all staff working on each shift, with an indication of who is in charge at any given time and any absences, substitutions, or other changes noted on the schedule.
Evidence
  1. *The Monthly Work Schedules for April 18, 2021-May 25, 2021 submitted by the facility were not updated to reflect absences or days worked for each staff member as indicated by the Timecard Reports during the same time period. The written work schedule was not updated to reflect the following: Staff # 1-4 worked a combined total of (39) thirty nine 7am -3pm shifts. Staff #7 worked one 7am -3pm shift and (2) two 3pm -11pm shifts. Staff #4 worked (9) nine 3pm -11pm shifts. Staff # 8-13 worked a combined total of (19) nineteen 3pm -11pm shifts. Staff # 3-4, #8, #11, #13 worked a combined total of (16) sixteen 11pm -7am shifts. Staff # 5-6 worked a combined total of (17) seventeen 7 -3 shifts. *The names and job classifications for Staff #5 and Staff #6 were not listed on the Monthly Work Schedule.
Plan of correction
Not published by VDSS.
22VAC40-73-680-C
Based on a review of the Med Variance report, the facility failed to ensure that medications were administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except for those drugs that are ordered for specific times.
Evidence
  1. A review of the Med Variance Report dated April 18 - May 25, 2021 reflected the following: Resident #1:
  2. Upon review of the Med Variance Report, approximately 64 prescription medication doses were administered more than one hour after the facility's standard dosing schedule.
  3. Late administration times ranged from approximately 43 minutes to 2.5 hours. a. Staff #3 did not document why medications were administered late. b. Staff #7 documented "7" as the reason for late administration. c. Staff #13 documented, "link" or did not document reason for later administration. Resident #2:
  4. Upon review of the Med Variance Report, approximately 20 prescription medication doses administered more than one hour after the facility's standard dosing schedule.
  5. Late administration times ranged from approximately 7 minutes to approximately 26 minutes. a. Staff #4 documented, "got here late" as the reason for late administration. b. Staff #7 documented, "4" and "330" as the reason for later administration. c. Staff #16 documented, "late" as the reason for late administration. Resident #3:
  6. Upon review of the Med Variance Report, approximately 16 prescription medication doses administered more than one hour after the facility's standard dosing schedule.
  7. Late administration times ranged from approximately 13 minutes approximately two hours and 36 minutes. a. Staff #3 documented "7" or did not document a reason for late administration. b. Staff #12 documented, "gave" as the reason for late administration. c. Staff #16 documented, "late" as the reason for late administration. Resident #4:
  8. Upon review of the Med Variance Report, approximately 12 prescription medication doses administered more than one hour after the facility's standard dosing schedule.
  9. Late administration times range from approximately 30 minutes to approximately 54 minutes.
  10. Staff #4 documented, "patient care", Staff #7 documented, "had to assist resident", "6" and "9", Staff #13 documented "link" as to why the medication was administered late. Resident #5:
  11. Upon review of the Med Variance Report, approximately 5 prescription medication doses administered more than one hour after the facility's standard dosing schedule.
  12. Late administration times was approximately 51 minutes.
  13. Staff #16 documented, "late" as to why the medication was administered late.
Plan of correction
Not published by VDSS.
22VAC40-73-680-D
Based on the review of resident records, the facility failed to administer medications in accordance with the physician's or other prescriber's instructions and consistent with standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Commonwealth of Virginia Board of Nursing Medication aide Curriculum for Registered Medication Aides, Revised May 21, 2013 states: a. Chapter 5, Section 5.1 titled, "5.1 Describe Three Types of Forms Commonly Used to Document Medication Administration" states, "Documentation is an important part of medication management. It is frequently referred to as the "6th Right" of medication administration". b. Section 5.3. titled "Document Medication Administration on the Medication Administration Record states, "All medications administered or omitted" under "What to Document".
  2. Upon review of the Medication Administration Records (MAR), no documentation of medication administration or omission was completed on the April 2021 and May 2021 MAR for the following: a. Resident #1: one medication (totaling 3 doses) scheduled 2:00pm on 4/17/-18 and 4/29, 2021, one medication (totaling 2 doses) scheduled for 2:00pm on 4/1 and 4/29, 2021, and one medication totaling two does scheduled for 6:00pm on 4/1 and 4/18, 2021, two medications (totaling 8 doses) scheduled for 2:00pm on 5/6, 5/24-25, and 5/27/2021, and one medication (totaling 2 doses) scheduled for 10:00pm on 5/9 and 5/24/2021. Diagnosis for these medications included muscle spasms, mood stabilizer, insomnia, and diabetes mellitus. b. Resident #2: one medication (totaling 3 doses) scheduled for 2:00pm on 4/17-4/18 and 4/29, 2021, one medication (totaling 6 doses) scheduled for 12:00pm on 5/21 and 2:00pm on 5/6, 5/24-25, 5/27, and 5/31, 2021. Diagnosis for this medication was Parkinson's Disease. c. Resident #3: one medication (totaling 2 doses) scheduled for 7:00pm on 4/2 and 11:00am on 4/21/2021 and one medication (totaling 6 doses) scheduled for 11:00am on 5/10, 5/14, 5/21, 5/24, and 5/28, 2021 and 7:00pm on 5/2/2021. Diagnosis for this medication was yeast infection.
Plan of correction
Not published by VDSS.
22VAC40-73-680-H
Based on a review of the Medication Administration Records (MAR), the facility failed to document on the medication administration records at the time the medication was administered.
Evidence
  1. Upon review of the Med Variance Report dated April 18, 2021 - May 25, 2021, the following was noted:
  2. Resident #1: a. Approximately fifty-one doses of prescription medication were not documented at the time of administration. b. Staff #3 documented "late post" and "late but given on time." c. Staff #7 documented, "7 pm forgot to record."
  3. Resident #2: a. Approximately seven doses of prescription medications were not documented at the time of administration. b. Staff #3 documented, "late post".
  4. Resident #3: a. Approximately 70 doses of prescription medications were not documented at the time of administration. b. Staff #3 documented, "late post, late post but given on time, and "7". c. Staff #7 documented, "late post".
  5. Resident #4: a. Approximately fifty-four doses of prescription medications were not documented at the time of administration. b. Staff #7 documented, "late post".
Plan of correction
Not published by VDSS.
December 2, 2020Complaint survey11 violations
Inspection dates
Dec. 2, 2020
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 12/2//2021 and concluded on 3/8/2021. A complaint was received by the department regarding allegations in the areas of Personnel; Staffing and Supervision; Resident Care and Related Services; and Building and Grounds. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. A virtual inspection and interview was also, completed. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-100-A
Based on a virtual tour of the building, the facility failed to implement the infection control program that is consistent with the federal Centers for Disease Control and Prevention (CDC) guidelines.
Evidence
  1. During the virtual tour on 2/9/2021, the staff member working in the kitchen was observed wearing her mask below her chin.
  2. The facility Policy and Procedure titled, ?Infection Control: Guidance for Management of (COVID) as set forth by Virginia Code 22VAC40-73-100“ with a ”Last Revision? date of 11/15/2020 received from the facility via e-mail on 1/6/2021 notes on page 5 under “Personal Protective Equipment (PPE) & Supplies” the following: a. ?Masks: In accordance with recently revised CDC Guidelines, masks are to be worn by all members of staff within the community at all times while in the building.?
Plan of correction
1. Dietary staff were immediately educated on mask mandate which requires them to be worn at all times and must properly cover both their nose and mouth. 2. All residents have the potential to be affected if facility staff fail to properly wear masks at all times. 3. Facility administrator or designee will educate all staff on CDC mask mandate requiring mouth and nose to be covered. 4. Facility administrator or designee will round daily x 5 per week x2 months to ensure all staff are following the required mask protocol. 5. Expected date of compliance: April 9, 2021.
22VAC40-73-190-A
Based on a review of documentation and an interview with staff the facility failed to ensure that when the administrator Description: Based on a review of documentation and an interview with staff, the facility failed to ensure that when the administrator, the designated assistant, or the manager is not awake and on duty on the premises, that there was a designated direct care staff member in charge of the premises.
Evidence
  1. The Daily Assignment sheet submitted upon request for 11/26/2020 noted Staff #1 was scheduled to work from 7-12, and Staff #3 from 3-11.
  2. The Timecard Report noted that on 11/26/2020, Staff #1 clocked out at 12:00pm and Staff #3 clocked in at 6:56pm.
  3. During a virtual interview on 2/9/2021, the administrator stated that Staff #7 was supposed to work from 12:00pm - 4:00pm because staff was working in four hour blocks for the Thanksgiving Holiday. The administrator stated that the staff member scheduled as the Medication Tech is the person in charge. The administrator stated that Staff #3 was running late.
  4. The Timecard Reported noted that no Medication Technician had clocked in between the hours of 12:00pm and 6:55pm. During a virtual interview on 2/9/2021, the administrator stated that ?there was no Medication Tech during that time so that is completely accurate and there was no one in charge.?
Plan of correction
1. Administrator was notified and immediately implemented emergency phone tree protocols to obtain coverage. 2. All residents have the potential to be affected if facility staff fail to properly designate coverage of person in charge when the administrator is not on the premises. 3. All staff will be educated on ensuring that there is, at all times, a designated person in charge prior to them leaving the center to ensure coverage when the Administrator is not on the premises. 4. Administrator or designee will conduct audits twice weekly x2 months to ensure that there are no further incidents of failure to designate person in charge when the Administrator is not on the premises. 5. Expected Date of Completion April 9, 2021
22VAC40-73-290-A
Based on a review of staff schedules and an interview with staff, the facility failed to maintain a written work schedule that includes the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time and any absences, substitutions, or other changes noted on the schedule.
Evidence
  1. The complainant stated that, while on site on 11/26/2020, no staff members could tell her who was in charge.
  2. Staff #1: a. The Monthly Work Schedule document for November 2020 submitted by the facility noted staff #1 as a Medication Technician (MT) on 11/26/2020 for the 7am-3pm shift. The Daily Assignment document dated 11/26/2020 submitted by the facility noted staff #1 was scheduled to work 7-12. The Time Card Report noted staff #1 clocked in at 6:50 am and clocked out at 12:00 pm.
  3. Staff #3: a. The Monthly Work Schedule document for November 2020 submitted by the facility did not note that staff #3 was scheduled to work on 11/26/2020. The Daily Assignment document dated 11/26/2020 noted staff #3 as “Med Tech/Charge” for 3-11. The Timecard Report noted that staff #3 clocked in at 06:56pm and clocked out at 11:00pm.
  4. Staff #7: a. The Monthly Work Schedule document for November 2020 submitted by the facility noted that staff #7 was scheduled to work on 11/26/2020 from 11pm - 7am. The Daily Assignment document dated 11/26/2020 noted staff #7 as working 11-7. b. The Timecard Report shows that staff #7 did not clock-in on 11/26/2020. c. During a virtual interview with the administrator on 2/9/2021, the administrator stated that staff #7 was supposed to work from 12n - 4pm on 11/26/2020 but did not come in to work.
  5. The facility did not maintain the November 2020 Monthly Staff Schedule to reflect any absences, substitutions on the schedule.
  6. The November 2020 Monthly Staff Schedule did not contain job classifications for: a. 7am - 3pm for staff #2, 3, 8, 9, or 10. b. 3pm - 11pm for staff #3, 7-8 and 10-16. c 11pm - 7am for staff #2, 7, 9, 12, 17, and 19.
Plan of correction
1. Facility Scheduler educated on regulation 22VAC40-73-(4)-290-A to ensure that she directs staff to notate any changes to the master schedule as they occur. 2. All residents have the potential to be affected if facility staff fail to maintain written work schedule notating any absences, substitutions, or other changes. 3. Facility staff will be educated on notating changes to the schedule as they occur and communicating those changes to the Administrator or designee. 4. Facility administrator or designee will monitor schedule and meet with scheduler twice weekly x2 months to ensure that all changes to the schedule are communicated and noted appropriately. 5. Expected date of compliance: April 9, 2021
22VAC40-73-290-B
Based on a virtual tour of the building and an interview with a staff member, the facility failed to implement a procedure to ensure that it posted the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public.
Evidence
  1. The complainant stated that she never knows who is in charge.
  2. During a virtual inspection on 2/9/2021, the administrator was asked to virtually show where the designated staff person in charge is posted. The administrator showed a medication room posting on a wall. Clarification was requested regarding where in the common area it was posted for visitors. The administrator stated that location was normally at the entrance to the facility in a frame but that it was not being posted currently since no visitors were coming in the facility due to the pandemic.
  3. It was requested that the area be shown during the virtual inspection. It was virtually shown that there was a picture frame in the lobby by the entrance on a table with a stop sign and a statement regarding visitation.
Plan of correction
1. Facility Scheduler educated on regulation 22VAC40-73-(4)-290-B to ensure that person in charge form is posted daily in a conspicuous place open to the public. 2. All residents have the potential to be affected if facility staff fail to post the person in charge notification daily in a conspicuous place open to the public as stated in 22VAC40-73(4)-290-B. 3. All Facility staff will be educated on ensuring the person in charge form is posted daily in a conspicuous place open to the public as stated in 22VAC40-73-(4)-290-B. 4. Facility administrator or designee will inspect 3 times weekly x2 months to ensure that the person in charge form is posted in a conspicuous place open to the public. 5. Expected date of completion: April 9, 2021.
22VAC40-73-300-B
Based on a review of facility documents the facility failed to provide a method of communication on all shifts that keeps direct care staff informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical and mental conditions.
Evidence
  1. Daily shift communication forms were reviewed for the month of November, 2020. The events of 11/26/2021 regarding medication omissions for all residents affected including resident #1 were not noted. The administrator reported "there are only about six of us so we make sure we tell each other" about any significant events.
Plan of correction
1. Facility staff were immediately educated on the use of their communication log to ensure shift to shift events, complaints, incidents and injuries related to physical and mental conditions. 2. All residents have the potential to be affected if facility staff fail to document events, incidents, complaints, and injuries related to residents physical and mental conditions. 3. Facility Administrator/DON or designee will educate all staff on the use of communication logs to document events, complaints, incidents, and injuries related to residents physical and mental conditions. 4. Facility administrator or designee will audit communication logs 5 times weekly x2 months to ensure staff document all events, complaints, incidents, and injuries related to a residents physical and mental condition. 5. Expected date of compliance: April 9, 2021.
22VAC40-73-640-A
Based on a review of the Medication Administration Services document in the Policy and Procedure Manual, the facility failed to ensure the written plan for medication management was kept current and included all of the components required by the standard.
Evidence
  1. The Medication Management Plan submitted for review via email on December 17, 2020 was not updated to reflect the new electronic Medication Administration Record (e-MAR) system that the staff began using in November 2020 and was not updated to include all of the components required by the standard.
  2. The Medication Administration Services document does not address the following: a. Methods to ensure an understanding of the responsibilities associated with medication management. b. Standard operating procedures including the facility’s standard dosing schedule and any general restrictions specific to the facility. c. Methods to prevent the use of outdated, damaged, or contaminated medications. d. Methods to ensure that each resident’s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed doses. e. Methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order. f. Methods for monitoring medication administration and the effective use of the MARs for documentation, methods to ensure that MARs are maintained as part of the resident’s record. g. Methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes, methods to ensure that staff who are responsible for administering medications meet the qualification requirements of 22 VAC 40-73-670. h. Methods to ensure that staff who are responsible for administering medications are adequately supervised, including periodic direct observation of medication administration. i. Methods to ensure that residents do not receive medications or dietary supplements to which they have known allergies. j. Methods to ensure that staff who are responsible for administering medications are trained on the facility’s medication management plan. k. Procedures for internal monitoring of the facility’s conformance to the medication management plan.
Plan of correction
1 Pharmacy was contacted to provide us with a new Medication Administration Policy to include our new electronic MAR Plan of Correction: 1. Pharmacy was contacted to provide us with a new Medication Administration Policy to include our new electronic MAR and all components required by this standard. New policy received 3/15/2021. 2. All residents have the potential to be affected if facility staff fail to ensure the written plan for Medication Administration/Management is kept current and includes all components required by standard 22 VAC40-73-(6)-640-A. 3. DON or designee will educate Medication Aides on the 22VAC40-73-(6)-640 standard requirements and the new Medication Administration Administration Policy that surrounds our new electronic MAR system. 4. DON or designee will educate Medication Aides on the Medication Administration Policy annually and within 90 days of hire to ensure compliance. 5. Expected Date of Completion; April 9, 2021.
22VAC40-73-680-C
Based on a review of the Med Variance report, the facility failed to ensure that medications were administered not earlier than one hour before and not later than one hour after the facility’s standard dosing schedule, except for those drugs that are ordered for specific times.
Evidence
  1. A complaint was received on 12/02/2020 stating the resident did not receive her insulin injections on time. Residents #1-#23:
  2. Upon review of the Med Variance Report, approximately 413 prescribed medications were administered more than one hour after scheduled administration time on November 1, 3, 5- 8, 13-15, 17-19, 2020.
  3. Late administration times ranged from approximately three minutes to approximately two hours and six minutes.
  4. Diagnosis for medications administered late include, but are not limited to pain, arthritis, hypertension, diabetes mellitus, blood pressure, anticoagulation, COPD, seizure disorder, mood disorder, thyroid, GERD, A-Fib, and dementia with behavioral disturbance.
  5. Staff #1 documented “First time user,” First time training,“ ”First time training,“ ”First Training Time,“ ”First Time Training,“ ”First time training,“ ”First time training,“ or ”First time training“ under ”Notes? as indicated on the Med Variance report for November 1 - 30, 2020. Residents #3, 5 - 7, 9 - 19, 21, and 22:
  6. Approximately 76 prescribed medication doses that were administered more than one hour prior to scheduled administration time on November 1,2,7,12,15,18, 2020.
  7. Late administration times ranged from approximately one minute to approximately 48 minutes.
  8. Diagnosis for medications administered late include, but not limited to, supplement, hypertension, rib cage pain, hyperlipidemia, cholesterol, Afib, diabetes mellitus, thyroid, bladder, allergies, seizures, memory, abdominal cramping, dementia, pain, OA pain, SPP, prophylaxis, Parkinson’s Disease, dry eyes, depression, mood disorder, back pain, and COPD.
  9. Staff #1 documented “First time training,” “First time training,” “First time user,” ?First day training,“ ”First training,“ or ”First day training? as indicated on the Med Variance report for November 1 - 30, 2020. Residents #6 and # 7:
  10. Approximately seven prescribed medication doses were administered more than one hour after the scheduled administration time on November 3 and November 7, 2020.
  11. Late administration times was approximately 14 minutes.
  12. Diagnosis for medications administered late include, but not limited to, cholesterol, Afib, diabetes mellitus, HTN, and thyroid.
  13. Staff #2 documented “First time training,” and “training” as indicated on the Med Variance report for November 1 - 30, 2020. Residents #2, 4 - 11, 13 - 15, 17 - 23:
  14. Approximately 43 prescribed medication doses were administered more than one hour after the scheduled administration time on November 1 and 5, 2020.
  15. Late administration times ranged from approximately 32 minutes to approximately seven hours and two minutes.
  16. Diagnoses for medications administered late include, but not limited to, poor appetite, dementia with behaviors, dementia, HTN, hypertiglyceridemia, diabetes mellitus, allergies, prophylaxis, pain osteoarthritis, anxiety/agitation, seizure disorder, seizures, depression, OA pain, Parkinson’s Disease, bipolar, dry eyes, A-fib, CHF, high blood pressure disorder, mood swings, osteoarthritis pain, and psychosis.
  17. Staff #4 documented “new to system”, “new to med pass”, “staff training”, “training” as indicated on the Med Variance report for November 1 - 30, 2020. **Due to the volume of information gathered during the inspection, a separate document has been created and is available upon request.***
Plan of correction
1. New administrator and Director of Nursing immediately set up training on electronic MAR system. Training completed on 12/10/2020. 2. All residents have the potential to be affected if facility staff fail to ensure medications are administered within one hour before/one hour after the ordered time as outlined in 22VAC40-73-(6)-680-C. 3. Medication Aides will be educated on use of the new MAR by DON or designee to ensure that they are aware of how to properly document and ensure medications are administered within the guidelines of facility dosing schedule. Administrator or designee will also evaluate the facility standard dosing schedule to ensure that medication administration times are optimal for all residents. 4. Don or designee will audit MAR's twice weekly x2 months to ensure that all medications are documented properly and administered within one hour before/one hour after time of order. 5. Expected Date of Completion: April 9, 2021.
22VAC40-73-680-D
Based on observation and the review of resident records, the facility failed to administer medications in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Commonwealth of Virginia Board of Nursing Medication Aide Curriculum for Registered Medication Aides, Revised May 21, 2013 states: a. Chapter 5, Section 5.1 titled, “ 5.1 ”Describe Three Types of Forms Commonly Used to Document Medication Administration “ states, ”Documentation is an important part of medication management. It is frequently referred to as the “6th Right” of medication administration. b. Section 5.3 titled ?Document Medication Administration on the Medication Administration Record states, “All medications administered or omitted” under ?What to Document.?
  2. The complainant stated that her parent did not receive any medications scheduled on 11/26/2020 between 2:00pm and 6:00pm.
  3. Upon review of the Medication Administration Records (MAR), no documentation of medication administration or omission was completed on the November 2020 MAR for the following: a. Resident #1: All medication (two medications totaling six medication doses) scheduled for 2:00pm on 11/23-24 and 26, 2020, all 9:00pm doses (four medications totaling 16 medication doses) on 11/21-22, 11/ 24 and 11/30, 2020, and one medication (totaling one dose) scheduled for 4:00pm on 11/26/2020, all medications. Diagnoses for these medications include spasms, anxiety, allergies, and mood. All medications (eight medications totaling eight medication doses) scheduled for 11:00am on 12/9/2020, one medication totaling one medication dose scheduled for 11:00am on 12/25/2020, two medications totaling six medication doses scheduled for 2:00pm on 12/4, 12/9, and 12/25, 2020, all medications (four medications totaling 32 medication doses) scheduled for 9:00am on 12/5, 12/7, 12/10,12/14, 12/23-25, and 12/30,
  4. Diagnoses for these medications include mood, anxiety, allergies, spasm, depression, hypothyroidism, hypertension, and diabetes mellitus. b. Resident #4: One medication totaling one medication dose) scheduled for 8:00am on 12/13/2020, seven medications totaling seven medication doses scheduled for 9:00am on 12/13/2020. Diagnoses for these medications were not included on the MAR. c. Resident #7: All medications scheduled for November 26, 2020 at 5:00pm (two medications totaling two doses). Diagnoses for these medications include seizures and allergies. d. Resident #8: Five medications (totaling five medication doses) scheduled for 8:00am on 11/3/2020, two medications (totaling two medication doses) scheduled for 4:00pm on 11/2 and 11/26, 2020, one medication (totaling two medication doses) scheduled for 5:00pm scheduled for 11/2 and 11/26, one medication (totaling one medication dose) scheduled for 8:00pm on 11/24,2020, and one medication (totaling one medication dose) scheduled for 11/24/2020 at 7:00am. Diagnoses for these medications include hypertension, prophylaxis, MDD-R, GERD, and hypothyroidism. **Due to the volume of information gathered during the inspection, a separate document has been created and is available upon request.***
Plan of correction
1. Administrator made aware. Physician made aware. Medication Aide administered missed medications where appropriate. 2. All residents have the potential to be affected if facility staff fail to ensure medications are administered per physician's orders and instructions. 3. Medication Aides will be educated on medication administration by physician's order and/or instructions as well as standards of practice set forth in the Registered Medication Aide Curriculum. 4. DON or designee will observe medication pass weekly x2months to ensure clinical staff are administering medications per physician's order and instruction. 5. Expected Date of Completion: April 9, 2021.
22VAC40-73-680-I
Based on a review of the Medication Administration Records the facility failed to document on the resident MAR's the diagnosis, condition, or specific indications for administering the drug or supplement.
Evidence
  1. Following are a list of residents and the name of the drug prescribed that did not have diagnosis, condition, or specific indications for administering the drug or supplement on the November, 2020 MAR. Resident #14- Afluria Quad 2020-21 (3YR UP) PRN Resident # 3 - Bumetanide 1 mg tablet; Afluria Quad 2020-21 (3 YR UP) PRN Resident # 7 - Xarelto 20mg tablet; Afluria Quad 2020-21 (3 YR UP) PRN Resident # 8 - Afluria Quad 2020-21 (3 YR UP) PRN Resident # 1 - Clopidogrel 75mg tabs; Afluria Quad 2020-21 (3 YR UP) PRN; Loperamide HCL 2mg caps; Ondansetron 4mg ODT tab Resident #13 - Afluria Quad 2020-21 (3 YR UP) PRN; Cyclobenzaprine 10mg tab Resident #14 - Afluria Quad 20-21 QIV PFS PRN Resident #15 - Afluria Quad 2020-21 (3 YR UP) PRN Resident #16 - Calcitonin/SALM 200U SPY 3.7ml; Ferrous Sulf 325 mg tab; Furosemide 20mg tab; Prednisone 5mg tablet; Tamsulosin HCL 0.4mg capsule Resident #18 - Cefuroxime Axetil 250mg tab; Spironolactone 25mg tab Resident #19 - Baclofen 5mg tablet; Cetirizine 10mg; Clonidine 0 1mg tab; Escitalopram 10mg tab; Simvastatin 20mg tab Resident #19 Baclofen 5mg tablet; Cetirizine 10mg; Clonidine 0.1mg tab; Escitalopram 10mg tab; Simvastatin 20mg tab Resident #22 - Docusate Sodium 100mg capsule; Afluria Quad 2020-21 (3 YR UP) PRN; Ondansetron 4mg ODT tab
Plan of correction
1. Facility Administrator/DON/Pharmacy consultant conducted 100% audit of all current residents to ensure that all orders include diagnosis, condition or specific indications for administering each drug or supplement on all orders entered onto the MAR. 2. All residents have the potential to be affected if facility staff fail to ensure all orders include diagnosis, condition, or specific indications for administering each drug or supplement on MAR's. 3. DON or designee will audit all new orders weekly x2 months to ensure that they include diagnosis, condition or specific indications for administering each drug or supplement on all orders entered on the MAR. 4. Facility administrator or designee will audit all MAR's monthly x2 months to ensure orders include diagnosis, condition or specific indications for administering each drug or supplement. 5. Expected date of compliance: April 9, 2021.
22VAC40-73-680-J
Based on interviews with facility staff and a collateral interview, the facility failed to ensure that in the event of a medication error, the resident’s physician of record was notified as soon as possible and failed to ensure that actions taken were documented in the resident’s record.
Evidence
  1. Section 5.4 titled “Document Medication Errors” in the registered medication aide curriculum approved by the Virginia Board of Nursing (Revised May 21, 2013) states ?When a medication is not given as prescribed by the HCP, a medication error has occurred.?
  2. A collateral telephone interview was held on 12/29/2020 with the prescriber who stated she was not notified by the facility that residents under care did not receive their prescribed medication scheduled between noon and 6:55pm on 11/26/2020.
  3. The administrator, during a 2/9/2021 virtual interview, stated that she contacted the Nurse Practitioner herself on Thanksgiving Evening regarding Resident #1.
  4. Upon request, the facility submitted all documentation completed in all resident records on 11/26/2020. Documentation for two residents were received.
  5. During a 2/9/2021 virtual interview with the administrator, the administrator acknowledged that no documentation was completed for medication error for resident #1 on 11/26/2020.
Plan of correction
1. Physician notified of errors and all records have been noted accordingly. 2. All residents have the potential to be affected if facility staff fail to ensure medication aides properly document and follow medication error protocols. 3. Medication Aides will be educated on Medication Error protocols set forth in Spring Oak Assisted Living Policy and Procedure Manual. 4. DON or designee will audit MAR's and Medication variance reports twice weekly x2 months to ensure medication errors are properly documented and protocols are followed. 5. Expected Date of Completion April 9, 2021.
22VAC40-73-930-B
Based on staff and resident interviews the facility failed to have a fully functional signaling device that allowed staff to determine the origin of the signal in a manner that was both audible and visible so that the staff was able to determine the origin of the signal.
Evidence
  1. On 11/28/21 resident #1 reported they attempted to use the pull the cord on the call bell signaling system with no staff response. The administrator reported that on that date the speaker system wasn’t working but is now repaired. The call bell lit up in a central location but there was no sound.
Plan of correction
1. Administrator contacted technician and had part ordered as soon as the annunciator was reported to be not audibly sounding. Residents were provided with hand bells. This has since been replaced and is fully functional. 2. All residents have the potential to be affected if facility signaling device is not fully functional. 3. All staff will be educated to ensure that they continue to report any such outage to management immediately. 4. Facility signaling device will be tested from randomly selected rooms weekly x2 months to ensure full functionality. 5. Expected date of compliance: April 9, 2021