46
Inspections
On record
16
With violations
Visits that cited something
30
Clean visits
Nothing cited
48
Violations cited
Individual findings
30
Standards cited
Distinct rules
24
Complaint visits
Prompted by a complaint
Spring Oak Bedford was inspected 46 times between December 22, 2022 and January 30, 2026 by the Virginia Department of Social Services. 16 of those visits ended with violations cited and 30 with none. Across that history VDSS cited 48 violations under 30 distinct standards. 24 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.
Every inspection listed here is currently published on the VDSS site.
Provider Information
Facility type
Assisted Living Facility
License type
One Year
License expires
09/19/2026
Administrator
Skye Grant
Licensing inspector
Mari Gentry
Inspector phone
(804) 845-0851
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit
Inspection History
46Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.
January 30, 2026Inspection0 violations
Inspection dates
01/30/2026, 03/05/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 01/30/2026 9:30AM to 10:30AM and 03/05/2026 2:00PM to 2:20PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-reported incident was received by VDSS Division of Licensing on 01/23/2026 regarding allegations in the area of: resident care and related services
Number of resident records reviewed: 1
Number of staff records reviewed: N/A/
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the self-report 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 30, 2026Complaint survey0 violations
Inspection dates
01/30/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
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: 01/30/2026 9:30AM to 12:00PM
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 01/27/2026 regarding allegations in the area of: resident care and related services
Number of resident records reviewed: 1
Number of interviews conducted with staff: 2
An exit meeting will be conducted to review the inspection findings.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 13, 2026Complaint survey0 violations
Inspection dates
01/13/2026
Areas reviewed
22VAC40-73 BUILDINGS AND GROUNDS22VAC40-80 COMPLAINT INVESTIGATION
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: 01/13/2026 8:45AM to 11:15AM
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 10/25/2025 regarding allegations in the area of: buildings and grounds
Number of residents present at the facility at the beginning of the inspection: 99
The licensing inspector completed a tour of the physical plant that included the building.
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 1
An exit meeting will be conducted to review the inspection findings.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 13, 2026Complaint survey0 violations
Inspection dates
01/13/2026
Areas reviewed
22VAC40-73 BUILDINGS AND GROUNDS22VAC40-80 COMPLAINT INVESTIGATION
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: 01/13/2026 8:45AM to 11:15AM
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 12/10/2025 regarding allegations in the area of: buildings and grounds
Number of residents present at the facility at the beginning of the inspection: 99
The licensing inspector completed a tour of the physical plant that included the building.
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
An exit meeting will be conducted to review the inspection findings.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 13, 2026Complaint survey0 violations
Inspection dates
01/13/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
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: 01/13/2026 8:45AM to 11:15AM
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 10/27/2025 regarding allegations in the area of: resident care and related services
Number of residents present at the facility at the beginning of the inspection: 99
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 3
An exit meeting will be conducted to review the inspection findings.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 13, 2026Inspection0 violations
Inspection dates
01/13/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 01/13/2026 8:45AM to 11:15AM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-reported incident was received by VDSS Division of Licensing on 01/02/2026 regarding allegations in the area of: resident care and related services
Number of residents present at the facility at the beginning of the inspection: 99
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
An exit meeting will be conducted to review the inspection findings.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 13, 2026Inspection0 violations
Inspection dates
01/13/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 01/13/2026 8:45AM to 11:15AM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-reported incident was received by VDSS Division of Licensing on 10/20/2025 regarding allegations in the area of: resident care and related services
Number of residents present at the facility at the beginning of the inspection: 99
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
An exit meeting will be conducted to review the inspection findings.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 24, 2025Complaint survey0 violations
Inspection dates
09/24/2025
Areas reviewed
22VAC40-73 BUILDINGS AND GROUNDS22VAC40-80 COMPLAINT INVESTIGATION
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: 09/24/2025 9:11AM to 9:25AM
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 09/22/2025 regarding allegations in the area of: buildings and grounds
An exit meeting will be conducted to review the inspection findings.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 29, 2025Inspection1 violation
Inspection dates
08/29/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 08/29/2025 9:40AM to 10:17AM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-reported incident was received by VDSS Division of Licensing on 08/02/2025 regarding allegations in the area of: resident care and related services
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-550-C
Based on staff interviews and a review of facility documentation, the facility failed to ensure that a resident of the assisted living facility had the rights and responsibilities as provided in 63.2-1808 of the Code of Virginia and this chapter.
Evidence
- The licensing inspector (LI) received a self-reported incident via email on 08/02/2025 from staff person 1. Staff person 1 reported that on 08/01/2025 at 4:00PM, resident 1’s family member reported that the resident’s bank alerted them regarding a pending check in which the signature on the check did not match the resident’s signature. A copy of the check was brought into the facility and upon a review of the check, the check was made out to an individual with the same last name as staff person 2. Upon further review, an individual with the same last name is listed as staff person 2’s emergency contact and staff person 2 was suspended pending an Adult Protective Services (APS) investigation.
- During on-site inspection on 08/29/2025, staff persons 3 and 4 provided the LI with a written statement from staff person 5 who was the staff person that was made aware of this situation on 08/01/2025. Staff person 5 stated in her written statement that the resident’s family member explained to her that they received notification from the bank regarding the resident’s account and that the resident’s family members went to the bank and obtained a copy of the questionable check that had been written. Staff person 5 took a picture of the check copy that was obtained by the resident’s family.
- Staff persons 3 and 4 provided the LI a copy of the cashed check that was provided to the resident’s family by the bank. Staff persons 3 and 4 stated that the check was written out to staff person 2’s emergency contact and was for $750.00. This incident violates resident 1’s right to be free from economic abuse or exploitation.
- Staff person 3 informed the LI that staff person 2 is being terminated and provided the LI with a copy of the termination letter that was sent to staff person 2 on 08/29/2025.
Plan of correction
The Executive Director, Director of Wellness, or designee will educate staff on resident's rights and resident misappropriation.
Compliance date: 9/16/25
August 29, 2025Complaint survey0 violations
Inspection dates
08/29/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
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: 08/29/2025 8:35AM to 9:40AM
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 08/19/2025 regarding allegations in the area(s) of: resident care and related services & buildings and grounds
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
An exit meeting will be conducted to review the inspection findings.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 30, 2025Inspection1 violation
Inspection dates
07/30/2025
Areas reviewed
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: 07/30/2025 10:00AM to 12:30PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-reported incident was received by VDSS Division of Licensing on 07/21/2025 regarding allegations in the area of: additional requirements for facilities that care for adults with serious cognitive impairments
Number of residents present at the facility at the beginning of the inspection: 98
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 5
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident record review and staff interviews, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
- The record for resident 1 contains a signed physician’s order, dated 07/10/2025, for Hydroxyzine (Vistaril) 50MG by mouth twice daily as needed for anxiety as evidenced by pacing, verbal agitation, exit seeking, restlessness; if signs/symptoms persist, update DON and/or supervisor.
- During an interview on 07/30/2025 with staff person 1, staff person 1 informed the LI that staff person 2 had paged her on 07/20/2025 after lunch sometime between 12:30PM and 1:30PM, to come and assist with resident 1. Resident 1 was outside in the courtyard and the resident was trying to jump over the courtyard fence. Staff person 1 stated that when she started going toward the courtyard, staff person 2 had already gotten the resident back in the safe, secure unit.
- During a phone interview on 07/31/2025 with staff person 2, staff person 2 informed the LI that on 07/20/2025 after lunch, between 12:30PM and 1:30PM, the resident was outside in the courtyard, had pushed a chair up to the fence and was trying to jump the fence. Staff person 2 stated that there was an individual (not a facility employee) who was on the other side of the fence trying to assist with calming the resident down. Staff person 2 stated she had paged staff person 1 for assistance but had gotten the resident back into the safe, secure unit and met staff person 1 in the hallway of the safe, secure unit. Staff person 2 informed the LI that she did not document this incident that occurred with the resident and also did not inform staff person 3, who was the registered medication aide (RMA) on duty at the time.
- Staff person 2 stated during the interview that at around 2:00PM on 07/20/2025, she heard a loud bang/noise and started going around to resident rooms to see where the noise came from. Staff person 2 stated she went into resident 1’s room and observed that the resident’s window was broken and the resident was outside of the facility (resident had climbed through the broken window) and was standing with two individuals who were not facility employees.
- Staff person 3, informed the LI during a phone interview on 08/01/2025 that she was not aware of the incident of the resident trying to climb over the courtyard fence between 12:30PM and 1:30PM and therefore, she did not administer the PRN Hydroxyzine to the resident.
- The licensing inspector (LI) received a self-reported incident from staff person 4 via email on 07/21/2025 at 3:07PM that on 07/20/2025 at 3:15PM staff were alerted to a loud noise and observed resident 1 with a plastic crate, breaking a glass window in room attempting to climb out, staff assisted the resident through window to administer first aid, the resident was sent to the ER for evaluation and was then administered an emergency custody order and transported to a local hospital. The self-reported incident also stated that the resident has been discharged from the facility.
- Staff person 5 documented on 07/20/2025 at 2:30PM that she was called to the facility by medication aid, stating that the resident had thrown a basket out window and it shattered, aid stated she heard loud noise and went into room when resident was climbing out of window, she said two ladies were assisting her out and that she called medication aide then helped the resident. Staff person 5 also stated in her note that when she arrived at the facility the resident was standing with police officer and staff, and EMS arrived. Resident had a small skin tear to left side of pinky – RMA applied first aid, but EMS readdressed, resident stated she just wanted to go home. Resident was then sent to ER via police officer for evaluation.
Plan of correction
The Director of Wellness or designee will educate medication administration staff on the process of administering medications in accordance with physician/prescriber instructions.
July 8, 2025Inspection7 violations
Inspection dates
07/08/2025
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: 07/08/2025 7:45AM to 2:45PM
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: 98
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
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 5
Observations by licensing inspector: breakfast, noon-time meal, medication administration, medication cart audit
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-M
Based on observation during medication cart audit, resident record review and staff interview, the facility failed to ensure medications ordered for PRN (as needed) administration shall be available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
- The record for resident 3 contains a signed physician’s order, dated 06/13/2025, for Diclofenac Sodium 1% gel apply 2GM topically to affected areas four times daily as needed for pain and Nicotine Trans 14MG/24Hour patch apply 1 patch transdermally once a day as needed for smoking cessation.
- Interview with staff person 5 revealed that the aforementioned PRN medications were not available on the medication cart or in the building for resident 3.
Plan of correction
Review medication management plan and DON or designee will routinely review all medication to ensure they are present and properly stored.
22VAC40-73-560-F
Based on observation, the facility failed to ensure that all records are treated confidentially, and that information shall be made available only when needed for the care of the residents.
Evidence
- During the physical plant walk-through on the date of inspection, the licensing inspector (LI) and collateral 1 observed an unattended medication cart sitting outside of A cottage at 09:18 AM.
- On top of that medication cart was a binder with a label stating A/B NARC BOOK down the side and the same on a page inside the front cover.
- Inside of the book there were forms called CONTROLLED DRUG RECORD for numerous residents which contained the resident names, dates of birth, prescribed narcotic medications, and the residents’ diagnoses that the narcotics are used to treat.
- When LI and collateral 1 walked away from the medication cart at 09:21 AM, there was and had not been any medication staff or nursing staff administering medications from that cart.
Plan of correction
Education for staff regarding resident records and HIPAA.
22VAC40-73-950-E
Based on facility documentation review and staff interview, the facility failed to ensure its semi-annual review on its emergency preparedness plan for all residents shall be documented by signing and dating.
Evidence
- The licensing inspector (LI) was provided documentation by staff person 5 during on-site inspection on 07/08/2025 that the facility had reviewed its emergency preparedness and response plan with residents on 04/04/2025; however, interview with staff person 5 revealed that residents did not sign and date acknowledging that they had received the review.
Plan of correction
Review will be completed biannually and signed by all residents, acknowledging the review of the emergency preparedness plan.
22VAC40-73-860-G
Based on observation during a tour of the building, the facility failed to ensure hot water taps available to residents shall be maintained within a range of 105 degrees Fahrenheit to 120 degrees Fahrenheit.
Evidence
- During on-site inspection on 07/08/2025, the licensing inspector (LI), Collateral 1 and staff person 4 noted that the hot water from the sinks in the restrooms in the facility’s memory care unit across from the dining room measured at 138 degrees Fahrenheit and 139 degrees Fahrenheit, the hot water from the sink in the restroom across from room H-111 was measured at 134 degrees Fahrenheit, the hot water from the sink in room H-104 was measured at 134 degrees Fahrenheit and the hot water from the bathroom sink in resident 8’s room was measured at 94.5 degrees Fahrenheit.
Plan of correction
Witt Mechanical was called in to service and adjust the hot water temperature in the Memory Care unit.
22VAC40-73-870-A
Based on observation during a tour of the building, the facility failed to ensure the interior of all buildings shall be maintained in good repair and kept clean.
Evidence
- At approximately 8:53AM, two licensing inspectors (LIs), Collateral 1 and staff person 4 noted a plastic urinal in resident 9’s room on the bedside table that contained a dark yellow substance with an odor and observed small black insects flying around the plastic urinal.
- At approximately 9:15AM, two LIs, Collateral 1 and staff person 4 noted numerous items of trash on the floor by resident 10’s bed and a stained area of carpet under the right side of the resident’s bed and under the bedside table. Also, resident 10 has a cat living in their room and in resident 10’s bathroom, there was a litter box that contained multiple areas of clumped urine and/or feces and litter on the floor around the litter box.
Plan of correction
Education provided to staff on regulation and review of housekeeping standards.
22VAC40-73-640-A
Based on medication cart audit and staff interview, the facility failed to ensure to implement its medication management plan in regard to methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
- The facility’s medication management plan provided during on-site inspection on 07/08/2025 states on page 4 that during shift change, all narcotics, cards, bottles, sheets are counted and recorded by the oncoming and off going medication aide/nurse, the oncoming and off going medication persons both sign off on the accurate counts of all narcotics on the narcotic administration record, in the event the staff member counting the controlled medications and realize that there is an issue with the count, will need to contact the DON/ADON at that time, the staff member responsible for the medication cart for that shift will need to stay until the DON/ADON arrives to address the issue, before the on coming staff can take the keys. Interview with staff person 5 confirmed that the on-coming and off-going medication staff persons are to not sign the controlled drug – shift - shift count record until both staff persons have confirmed an accurate count of narcotics.
- The controlled drug – shift -shift count records in the facility’s memory care medication cart and the facility’s Christiansburg’s medication cart both contained multiple instances that did not contain the signature of either the on-coming or off- going medication staff person. In addition, at approximately 11:24AM during on-site inspection on 07/08/2025, the controlled drug – shift – shift count record in the facility’s memory care medication cart contained the signature of staff person 3 in the nurse off-going 7-3PM for 07/08/2025. Staff person 3 acknowledged that they had signed already as the off-going medication on this date even though they should not have as they were not able to count with the 3-11PM medication staff person.
Plan of correction
DON or designee to review the medication management plan with all medication administration staff.
22VAC40-73-880-C
Based on observation, the facility failed to ensure temperatures in all areas used by residents shall not exceed 80 degrees Fahrenheit.
Evidence
- During the afternoon of the on-site inspection on 07/08/2025 between 1:00PM and 1:30PM, the following temperatures were noted by the licensing inspectors (LIs), Collateral 1 and staff person 6: in the hallway between D Cottage and the dining room was 84 degrees Fahrenheit, the main hallway of D Cottage was 84.2 degrees Fahrenheit, the hallway outside of C Cottage was 81.7 degrees Fahrenheit and the hallway outside of B Cottage was 81.9 degrees Fahrenheit.
Plan of correction
Spring Oak Bedford ordered twenty (20) new Bosch Water Source Heat Pumps to address cooling deficiencies in B, C, and D Cottage hallways. These units are currently on a 20-week lead time. In the interim, the facility will increase the number of portable air conditioning units to maintain compliance with temperature regulations.
July 8, 2025Complaint survey0 violations
Inspection dates
07/08/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/08/2025 7:45AM to 2:45PM
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 05/29/2025 regarding allegations in the area of: resident care and related services
Number of residents present at the facility at the beginning of the inspection: 98
Number of resident records reviewed: 1
Number of interviews conducted with staff: 3
An exit meeting will be conducted to review the inspection findings.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 28, 2025Inspection2 violations
Inspection dates
05/28/2025, 05/29/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 05/28/2025 1:00PM to 4:00PM and 05/29/2025 8:43AM to 9:50AM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
Two self-reported incidents were received by VDSS Division of Licensing on 05/26/2025 and 05/27/2025 regarding allegations in the areas of: resident care and related services
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 4
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported some, but not all of the self-reported incidents; area(s) of non-compliance with standard(s) or law were: medication administration
A violation notice was issued; any violation(s) not related to the self-reports 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure medications were administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
- Staff person 1 emailed the licensing inspector (LI) a self-reported incident on 05/27/2025 that there was an audit completed of resident 1’s medications During the audit, it was discovered that staff person 3 had documented that medications were administered to resident 1; however, the resident was known to have not been in the building on the date and time when staff person 3 documented medications were administered to him.
- The record for resident 1 contains a signed physician’s order, dated 05/15/2025, for Advair inhale 1 puff by mouth twice daily for COPD, Amiodarone 200MG take one tablet by mouth every day for Afib, Eliquis 5MG take one tablet by mouth twice daily for stroke prevention, Furosemide 40MG take one tablet by mouth twice daily for edema, Jardiance 10MG take one tablet by mouth every day for heart, Lisinopril 2.5MG take one tablet by mouth every day for heart health, Memantine 10MG take one tablet by mouth twice daily for dementia, Metoprolol 50MG take one tablet by mouth every day for hypertension, Risperidone 0.5MG take one tablet by mouth twice daily for psychosis and Vitamin D3 50MCG take one tablet by mouth every day for vitamin D deficiency. All the aforementioned medications are scheduled daily at 8:00AM.
- Staff person 3 revealed to the LI during on-site interview on 05/29/2025 that on the morning of 05/25/2025 sometime between 7:15AM and 8:00AM she saw the resident in the hallway and prepared his medications; however, when she was done preparing the resident’s medications, the resident was not in sight. Staff person 3 the proceeded to put the resident’s prepared medications in the top drawer of the medication cart and did not realize she hadn’t administered the resident his medications until later during the day on 05/25/2025 sometime between 3:00PM and 4:00PM when she went to start the afternoon medication administration. Staff person 3 then stated that when she got the prepared medications out of the top drawer of the medication cart to take to staff person 2, she dropped them all on the floor and disposed of them in a sharps box.
Plan of correction
Staff has reviewed the medication management plan, completed 4 hour medication refresher review, and proper disciplinary action and education has been provided to staff.
22VAC40-73-680-I
Based on resident record review, the facility failed to ensure the medication administration record (MAR) shall include any medication errors or omissions.
Evidence
- The May 2025 MAR for resident 1 contains staff person 3’s initials that they administered the resident’s scheduled 8:00AM medications on 05/25/2025; however, interview with staff person 3 on 05/29/2025 revealed that they did not administer the resident their scheduled 8:00AM medications on 05/25/2025. The May 2025 does not contain documentation that the medications were not administered to the resident. Staff person 3 confirmed this is accurate.
Plan of correction
MAR has been corrected and education has been provided to staff regarding proper documentation to medication errors or omissions.
May 23, 2025Complaint survey0 violations
Inspection dates
05/23/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS22VAC40-80 COMPLAINT INVESTIGATION
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: 05/23/2025 9:00AM to 11:20AM
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 05/21/2025 regarding allegations in the areas of: resident care and related services & additional requirements for facilities that care for adults with serious cognitive impairments
Number of residents present at the facility at the beginning of the inspection: 99
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 7
Observations by licensing inspector: activity in the memory care unit
An exit meeting will be conducted to review the inspection findings.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 23, 2025Complaint survey0 violations
Inspection dates
05/23/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
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: 05/23/2025 9:00AM to 10:10AM
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 05/12/2025 regarding allegations in the area(s) of: personnel and building & grounds
Number of residents present at the facility at the beginning of the inspection: 99
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 4
An exit meeting will be conducted to review the inspection findings.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 8, 2025Complaint survey1 violation
Inspection dates
05/08/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
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: 05/08/2025 8:37AM to 10:16AM
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 03/16/2025 regarding allegations in the area of: resident care and related services
Number of residents present at the facility at the beginning of the inspection: 106
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-460-H
Based on resident record review and staff interview, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with bathing at least twice a week, but more often if needed or desired.
Evidence
- The uniform assessment instrument (UAI) for resident 1, dated 03/14/2025, indicates that the resident requires mechanical help and human physical help with bathing. The individualized service plan (ISP) for resident 1, dated 03/14/2025, indicates that the resident requires physical help with bathing and mechanical help from grab bars and that the resident will be bathed twice weekly and as needed at the facility.
- Interview with staff persons 1 and 2 revealed that the facility utilizes shower calendars to have documentation for when a resident has received a shower/bath.
- The April Shower Calendar for April 2025 contains documentation that the resident only received one shower during the week of 04/06/2025 to 04/12/2025. Interview with staff person 2 confirmed this is accurate.
Plan of correction
Home health, staff, and hospice groups educated to record showers and/or refusals for showers on the Monthly Shower Calendar for the respective resident. Shower Calendars will be reviewed for compliance and accuracy.
May 8, 2025Inspection0 violations
Inspection dates
05/08/2025
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND
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: 05/08/2025 8:37AM to 11:20AM
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: 106
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
An exit meeting will be conducted to review the inspection findings.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 8, 2025Complaint survey0 violations
Inspection dates
05/08/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
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: 05/08/2025 8:37AM to 11:15AM
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 04/07/2025 regarding allegations in the area of: resident care and related services
Number of residents present at the facility at the beginning of the inspection: 106
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
An exit meeting will be conducted to review the inspection findings.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 23, 2025Complaint survey1 violation
Inspection dates
01/23/2025
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
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: 01/23/2025 10:00AM to 1:20PM
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 01/15/2025 regarding allegations in the area of: buildings and grounds
Number of residents present at the facility at the beginning of the inspection: 80
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 2
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.stokes@dss.virginia.gov
Violations
22VAC40-73-880-B
Based on a measurement of temperatures during a walkthrough of the facility and staff interview, the facility failed to ensure a temperature of at least 72 degrees Fahrenheit shall be maintained in all areas used by residents during hours when residents are normally awake.
Evidence
- During a walkthrough of the facility in the presence of staff persons 1 and 2, the following temperatures were measured by staff persons 1 and 2: 64 degrees Fahrenheit on the main level of A cottage, 62 degrees Fahrenheit on the bottom hall of B cottage, 68 degrees Fahrenheit on the top level of B cottage, 56 degrees Fahrenheit in the hallway outside of C cottage, 54 degrees Fahrenheit in the hallway outside of D cottage, 64 degrees Fahrenheit on the bottom hall of D cottage, 63 degrees Fahrenheit in the lobby, and 66 degrees Fahrenheit in the hallway outside of the dining room.
- Staff person 1 stated during an interview that the facility is currently experiencing issues with its heating system throughout some portions of the building.
Plan of correction
Current temperatures in common areas:
• Recreation Room: 75°F
• Library: 80°F
• Lobby: 75°F
• Dining Room: 72°F
Appropriate contractor reengaged for a proposal to address hallway heating needs. This was originally assumed to be included and addressed in the boiler replacement project.
Spring Oak Bedford hired a full-time mechanical expert, to monitor and maintain all heating and cooling systems, including resident room PTAC units.
Additional HVAC upgrades under review, as needed with appropriate contractors.
January 23, 2025Complaint survey1 violation
Inspection dates
01/23/2025
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
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: 01/23/2025 10:00AM to 1:20PM
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 01/10/2025 regarding allegations in the area of: buildings and grounds
Number of residents present at the facility at the beginning of the inspection: 80
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 2
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.stokes@dss.virginia.gov
Violations
22VAC40-73-880-B
Based on observation during a walkthrough of the facility and staff interview, the facility failed to ensure space heaters may be used only to provide or supplement heat in the event of a power failure or similar emergency provided their installation or operation has been approved by the state or local building or fire authorities.
Evidence
- During a walkthrough of the facility in the presence of staff persons 1 and 2, the following rooms were observed with a space heater that was plugged in and turned on in the following rooms that a resident or resident(s) currently reside in: Rooms B202, C101, C108, E102, and E203.
- Interview with staff person 1 revealed that the current use of space heaters has not been approved by the state or local building or fire authorities.
Plan of correction
All unapproved space heaters in resident rooms removed immediately.
Confirmed with the appropriate building official that space heaters may be used in resident rooms with proper fire watch protocols.
The building official confirmed additional staff or outside contractors are NOT required to comply with fire watch protocol.
Portable space heaters may only be used in resident rooms with active fire watch
January 23, 2025Complaint survey0 violations
Inspection dates
01/23/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
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: 01/23/2025 10:00AM to 1:20PM
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 12/31/2024 regarding allegations in the area of: resident care and related services
Number of residents present at the facility at the beginning of the inspection: 82
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
An exit meeting will be conducted to review the inspection findings.
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 Jennifer Stokes , Licensing Inspector at 540-589-5216 or by email at jennifer.stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 4, 2024Inspection0 violations
Inspection dates
09/04/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 BUILDINGS AND GROUNDS
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: 09/04/2024 9:40AM to 1:45PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Additional Comments/Discussion: The President/CEO of Spring Oak Living, the Administrator, the Licensing Administrator and the Licensing Inspector had a discussion regarding standards 22VAC40-73-880-B and 22VAC40-73-880-C.
An exit meeting will be conducted to review the inspection findings.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 4, 2024Inspection0 violations
Inspection dates
09/04/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 09/04/2024 9:40AM to 1:45PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-reported incident was received by VDSS Division of Licensing on 07/11/2024 regarding allegations in the areas of: personnel and resident care & related services
Number of staff records reviewed: 1
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the self-report 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 22, 2024Inspection0 violations
Inspection dates
08/22/2024, 09/04/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 08/22/2024 9:00AM to 10:15AM and 09/04/2024 9:40AM to 1:45PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-reported incident was received by VDSS Division of Licensing on 08/01/2024 regarding allegations in the areas of: personnel and resident care & related services
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the self-report 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 22, 2024Inspection5 violations
Inspection dates
07/22/2024, 07/23/2024
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 GROUNDS22VAC40-73 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: 07/22/2024 7:54AM until 3:50PM and 07/23/2024 8:05AM until 10:45AM
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: 85
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 5
Observations by licensing inspector: morning medication administration, medication cart audits, activity, noon-time meal
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on observation, staff interview and resident record review, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
- The record for resident 6 contains a signed physician’s order, dated 03/26/2024, for bupropn hcl 150MG tablet take three tablets by mouth every day at 8:00AM for depression.
- During medication cart audit on 07/23/2024, the licensing inspector (LI) noted that the medication card for the resident’s bupropn hcl 150MG contained three pills per blister/bubble. The LI and staff person 2 noted that the 8:00AM 07/23/2024 dose of bupropn hcl 150MG that had been popped out of the bubble pack/card by staff person 2 still contained one bupropn hcl pill indicating that the resident had only received two out of the three pills for the 07/23/2024 8:00AM dose. Interview with staff person 2 indicated that this was accurate and that they had only administered two tablets instead of three.
Plan of correction
ED/DON will in-service all RMA’s on the medication management plan.
22VAC40-73-950-E
Based on documentation review and staff interview, the facility failed to ensure its semi-annual review on its emergency preparedness and response plan for all staff, residents, and volunteers shall be documented by signing and dating.
Evidence
- The licensing inspector (LI) was provided documentation by staff persons 4 and 5 during on-site inspection that the facility had reviewed its emergency preparedness and response plan with residents on 03/14/2024; however, interview with staff persons 4 and 5 revealed that residents did not sign and date acknowledging that they had had the review. In addition, staff person 5 stated that staff person 1 had also reviewed the plan on 02/21/2024; however, staff person 5 was unable to produce evidence that staff person 1 had signed and dated that they had reviewed the plan.
Plan of correction
ED/BOM or designee will ensure that each resident, staff, and volunteers will have the emergency preparedness plan reviewed semi-annually and documented per state regulations requirements
22VAC40-73-880-C
Based on observation, the facility failed to ensure temperatures in all areas used by residents shall not exceed 80 degrees Fahrenheit.
Evidence
- Based on observation, the facility failed to ensure temperatures in all areas used by residents shall not exceed 80 degrees Fahrenheit. EVIDENCE: At approximately 2:52PM on 07/22/2024, it was noted by the licensing inspector (LI) and staff person 4 that the temperature in the common area on the second floor of E/F/G was 81.5 degrees Farhenhit and the hallway in the E cottage on the second floor was 83 degrees Farhenhit.
Plan of correction
ED or designee will ensure that two additional 10,000 BTU air conditioning units will be placed in the common area of E/F/G and in G hallway, respectively. Additionally, updated cooling towers have been ordered and will be installed upon arrival.
22VAC40-73-870-A
Based on observation during a tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean.
Evidence
- The carpet outside the main doors at the threshold to the dining room near the bulletin board was noted to have various areas of staining.
- The carpet on D cottage was noted to contain various areas of staining.
- At approximately 9:14AM on 07/22/2024, the licensing inspector (LI) noted that the carpet on the bottom level of D cottage at the exit door was wet from the door to the bottom of the stairs.
- The carpet in the hallway outside of the library and the A through D cottages was noted to have various areas of staining.
- The front of the building was noted to contain various areas of chipping white paint.
Plan of correction
Facility will obtain a commercial grade carpet cleaner to assist with the removal of stains as needed to maintain stain-free carpets.
22VAC40-73-280-C
Based on document review and staff interview, the facility failed to ensure an adequate number of staff persons shall be on the premises at all times to implement the approved fire and emergency evacuation plan.
Evidence
- During on-site inspection, interviews with staff persons 4 and 5 revealed that the facility does not have documentation of and is unaware of the adequate number of staff persons that are needed on the premises at all times to implement its approved fire and emergency evacuation plan.
Plan of correction
ED or designee will ensure during monthly safety committee meetings that management will discuss current resident acuity levels and determine the appropriate number of staff persons needed on the premises at all times to implement our approved fire and emergency evacuation plan.
June 13, 2024Complaint survey3 violations
Inspection dates
06/13/2024, 09/04/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
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: 06/13/2024 10:30AM to 2:00PM and 09/04/2024 9:30AM to 1:45PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by VDSS Division of Licensing on 06/13/2024 regarding allegations in the areas of: administration and administrative services & resident care and related services
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 6
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: resident care and related services
A violation notice was 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-300-B
Based on staff interview and documentation review, the facility failed to ensure a method of written communication shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions.
Evidence
- Resident 1 was admitted to the facility on 03/28/2024. During on-site inspection on 06/13/2024, the licensing inspector (LI) asked staff persons 1 and 2 to see the facility’s written communication from 03/28/2024 to 06/13/2024 that is utilized to keep direct care staff on all shifts informed of significant happenings or problems experienced by residents.
- Staff person 2 provided the document “Spring Oak MED AIDE TO MED AIDE 24-hour communication log” for 06/10-11/2024, 06/12-13/2024, and 06/13-14/2024 and informed the LI that they were not able to locate any additional communication logs for the cottage the resident resided on for the time period that was requested.
- The record for resident 1 contains observation notes from 03/28/2024 to 06/13/2024 regarding resident 1; however, the observation notes are only documented by registered medication aides (RMAs) and nurses and interview with staff person 2 revealed that other direct care staff persons cannot document in these notes or utilize these notes because they do not have the ability to access them on the computer.
Plan of correction
Form has been adjusted to 24 hour communication log, aide and med techs will be educated on use of the log and have access to view it at all times.
22VAC40-73-470-F
Based on resident record review, the facility failed to ensure when the resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately, the circumstances involved and the medical attention received or refused shall be documented in the resident’s record, the date and time of occurrence, as well as the personnel involved shall be included in the documentation, the resident’s physician, if not already involved, next of kin, legal representative, designated contact person, case manager, and any responsible social agency, as appropriate, shall be notified as soon as possible but no later than 24 hours from the situation and action taken and, if applicable, the resident’s refusal of medical attention and if a resident refuses medical attention, the resident’s physician shall be notified immediately.
Evidence
- Facility staff note for resident 1 documented by staff person 3, dated 06/01/2024 at 10:30PM, states that the resident has been vomiting all evening, was asked several times if she wanted to be sent out, resident refused to be sent out and that the resident was given ginger ale.
- The record for resident 1 does not contain documentation that the resident received medical attention from a licensed health care professional immediately (staff person 3 is not a licensed health care professional), does not contain documentation that the resident’s legal representative was notified of the incident of the resident’s refusal of medical attention or that the resident’s physician was notified of the resident’s refusal of medical attention.
Plan of correction
With ensure that the Director of Nursing or designee properly documents any abnormal medical concerns that are outside the residents baseline. The DON and or designee will assess the situation and properly make determination if outside medical attention is needed.
22VAC40-73-450-C
Based on resident record review, the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission and shall include a description of identified needs and date identified based upon the (i) UAI; (ii) admission physical examination; (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (vi) other sources.
Evidence
- The record for resident 1 contains a uniform assessment instrument (UAI) that was completed by Collateral 1, dated 02/21/2024, that indicates on page one that Collateral 2 is the resident’s legal guardian and conservator. In addition, the record for the resident contains a document that is an order appointing guardian for the resident, Collateral 2, dated and signed by a judge on 01/05/2023. The document states that resident 1 is incapacitated and is incapacitated to such an extent that she is unable to care for herself or make medical decisions and that her illness significantly impairs her capacity to exercise judgement and/or self-control and that such condition is unlikely to improve in the foreseeable future.
- The individualized service plan (ISP) for the resident, dated 04/26/2024, does not include information that the resident has a court appointed guardian.
Plan of correction
Resident files have been audited and will ensure ISPs accurately reflect Guardianship duties and responsibilities.
June 11, 2024Inspection1 violation
Inspection dates
06/11/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 06/11/2024 1:30PM until 2:20PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-reported incident was received by VDSS Division of Licensing on 06/10/2024 regarding allegations in the area of: resident care and related services
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self report 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident record review and staff and resident interview, the facility failed to ensure that medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
- The licensing inspector (LI) received an email from staff person 1 on 06/10/2024 that resident 1 had reported to staff person 2 that they believed they had not received their nighttime medications on 06/09/2024.
- Staff person 2 verified through interview with staff person 3 and the resident’s medication administration record (MAR) that the resident did not receive the following nighttime medications on 06/09/2024: donepezil 5MG, acetaminophen 325MG (take two tablets), docustate sod 100MG, diazepam 2MG and imipramine 25MG (take two tablets). It was verified with staff persons 1 and 2 that this is accurate.
Plan of correction
ED/DON will review MAR report daily in stand up from the previous day to ensure accuracy. ED/DON will sign off daily on the MAR report and place it in a binder for documentation.
May 29, 2024Complaint survey0 violations
Inspection dates
05/29/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
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: 05/29/2024 11:31AM until 2:00PM
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 04/30/2024 regarding allegations in the area of: resident care and related services
An exit meeting will be conducted to review the inspection findings.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 29, 2024Complaint survey2 violations
Inspection dates
05/29/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
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: 05/29/2024 11:30AM until 2:00PM
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 05/15/2024 regarding allegations in the area of: resident care and related services.
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-K
Based on resident record review, the facility failed to ensure the use of PRN medications is prohibited, unless the resident is capable of determining when the medication is needed, licensed health care professionals administer the PRN medications; or medication aides administer the PRN medication when the facility has obtained from the resident’s physician or other prescriber a detailed medication order and the order shall include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist.
Evidence
- Interview with staff person 1 confirmed that resident 1 has a diagnosis of dementia and would not be capable of determining when a PRN medication is needed. Resident 1 resided in the facility’s safe, secure unit.
- The record for resident 1 contains a physician’s order, dated 02/27/2024, for acetaminophen 325MG take two (2) tablets every six (6) hours as needed (PRN) for pain do not exceed 3,000MG within 24 hours. The March 2024 medication administration record (MAR) for resident 1 indicates that registered medication aides (RMAs) administered the resident acetaminophen one time on 03/05/2024, one time on 03/08/2024, and three times on 03/12/2024; however, the physician’s order does not include symptoms that indicate the use of the medication and directions as to what to do if symptoms persist.
- The record for resident 1 contains physician’s orders for the following PRN medications: hydroxyzine pamoate 25MG, dated 02/27/2024, take one (1) capsule every eight (8) hours as needed (PRN) for anxiety/agitation; quetiapine 50MG, dated 02/27/2024, take one (1) tablet every six (6) hours as needed (PRN) for severe anxiety/agitation; lorazepam 0.5MG, dated 03/28/2024, take one (1) tablet every six (6) hours as needed (PRN) for anxiety/agitation; and lorazepam 0.5MG, dated 04/11/2024, take one (1) tablet every six (6) hours as needed (PRN) for anxiety/agitation. The March 2024 MAR (03/01/2024 through 03/31/2024) for resident 1 indicates that hydroxyzine pamoate 25MG was administered to the resident by RMAs 22 times, quetiapine 50MG was administered to the resident by RMAs 19 times, and lorazepam 0.5MG was administered to the resident by RMAs 4 times throughout the month of March 2024. The April 2024 MAR (04/01/2024 through 04/17/2024) for resident 1 indicates that hydroxyzine pamoate 25MG was administered to the resident by RMAs 2 times, quetiapine 50MG was administered to the resident by RMAs 11 times, and lorazepam 0.5MG was administered to the resident by RMAs 16 times throughout the month of April 2024.
- The physician’s orders for the aforementioned PRN medications that were administered by RMAs throughout March 2024 and April 2024 do not include symptoms that indicate the use of the aforementioned PRN medications and directions as to what to do if symptoms persist.
Plan of correction
DON will complete upon admission and recert all PRNs every 6 month and as needed for accurate documentation for all RMAs to be able to identify symptoms, dosages, timeframes, directions if symptoms persist.
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
- The record for resident 1 contains a physician’s order for quetiapine 50MG, dated 02/27/2024, take one (1) tablet every six (6) hours as needed (PRN) for severe anxiety/agitation.
- The April 2024 medication administration record (MAR) for the resident indicates that on 04/11/2024 staff person 2 administered PRN quetiapine 50MG to the resident at 4:14PM and at 9:17PM; however, there had not been six hours since the resident received the first dose of quetiapine 50MG. Interview with staff person 1 on 06/04/2024 confirmed that this was accurate.
Plan of correction
DON/ED will Inservice all RMA’s on
The correct medication administration
For PRN’s and educate all RMA’s on
The documentation of physicians
Orders for PRN medication form.
May 29, 2024Complaint survey0 violations
Inspection dates
05/29/2024
Areas reviewed
22VAC40-73 BUILDINGS AND GROUNDS22VAC40-80 COMPLAINT INVESTIGATION
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: 05/29/2024 1:00PM until 1:25PM
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 05/24/2024 regarding allegations in the area of: buildings and grounds
An exit meeting will be conducted to review the inspection findings.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 17, 2024Inspection0 violations
Inspection dates
05/17/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 05/17/2024 9:00AM until 11:30AM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-reported incident was received by VDSS Division of Licensing on 05/14/2024 regarding allegations in the areas of: personnel and resident care and related services
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the self-report 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 23, 2024Inspection0 violations
Inspection dates
04/23/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 04/23/2024 9:55AM until 11:50AM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-reported incident was received by VDSS Division of Licensing on 04/22/2024 regarding allegations in the area(s) of: personnel and resident care and related services.
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the self-report 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 23, 2024Inspection0 violations
Inspection dates
04/23/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 04/23/2024 9:55AM until 11:50AM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-reported incident was received by VDSS Division of Licensing on 04/18/2024 regarding allegations in the area(s) of: personnel and resident care and related services.
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the self-report 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 23, 2024Inspection0 violations
Inspection dates
04/23/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 04/23/2024 9:55AM until 11:50AM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-reported incident was received by VDSS Division of Licensing on 04/09/2024 regarding allegations in the area(s) of: personnel and resident care and related services.
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the self-report 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 21, 2023Inspection0 violations
Inspection dates
11/21/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 11/21/2023 10:00AM until 11:45AM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-reported incident was received by VDSS Division of Licensing on 11/26/2023 regarding allegations in the area of: resident care and related services
An exit meeting will be conducted to review the inspection findings.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 25, 2023Complaint survey0 violations
Inspection dates
10/25/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
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: 10/25/2023 10:00AM until 11:45AM
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 10/13/2023 regarding allegations in the area of: resident care and related services
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the (allegation(s)/self-report) 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 5, 2023Complaint survey0 violations
Inspection dates
10/05/2023
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
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: 10/05/2023 10:00AM until 11:30AM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by VDSS Division of Licensing on 09/30/2023 regarding allegations in the areas of: staffing and supervision and resident care and related services.
An exit meeting will be conducted to review the inspection findings.
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.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 29, 2023Inspection1 violation
Inspection dates
09/29/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring
Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/29/2023 9:45AM until 10:13AM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A self-reported incident was received by VDSS Division of Licensing on 09/20/2023 regarding allegations in the area of: resident care and related services
The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
- The licensing inspector (LI) received an email from staff person 1 on 09/20/2023 that staff person 2 had administered Aricept 10MG to resident 1 on 09/19/2023 at 4:55PM; however, staff person 2 informed staff person 1 that resident 1 does not have a physician’s or other prescriber’s order for Aricept 10MG and had administered the medication to the resident incorrectly.
Plan of correction
DON will in-service staff Member on med administration and 5 rights of medication.
August 16, 2023Inspection10 violations
Inspection dates
08/16/2023
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 of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 08/16/2023 8:50AM until 3:45PM
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: 88
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of interviews conducted with residents: 5
Number of interviews conducted with staff: 5
Observations by licensing inspectors: medication pass, medication cart audits, activities
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-870-A
Based on observation of the facility physical plant, the facility failed to ensure the interior of the building is maintained in good repair and kept clean.
Evidence
- An overhead cabinet in room B-107 close to the window was noted to have a large area by the hinges that was damp and stained and the bottom corner of the cabinet close to the hinges was noted to be separating from the bottom base of the cabinet.
- During a walk-through of the facility physical plant, the following was observed from 9:18AM through 9:51AM during the on-site inspection: the ceiling in room A206, above the window in the right corner of the room, was noted to have a circular stain on a ceiling tile; the ceiling in the hallway near room B105, near the light fixture, was noted to have a stain; the ceiling in the stairwell in Cottage D on the 2nd floor, directly off the elevator, was noted to have a stain near the window and the ceiling in the walkway to Memory Care from the main building was noted to have multiple stains that were numerous sizes.
Plan of correction
Maintenance/ED/SMD will ensure during weekly room checks that all cabinets are looked at, as this room is not currently occupied.
22VAC40-73-640-A
Based on observations of the facility medication carts and policy review, the facility failed to implement their medication management plan regarding methods to ensure accurate counts of controlled substances whenever assigned medication administration staff changes.
Evidence
- The facility medication management plan provided to the licensing inspector on the day of inspection has documentation that “During shift change, all narcotics, cards, bottles, sheets are counted and recorded by the oncoming and off going medication aide/nurse. The oncoming and off going medication persons both sign off on the accurate counts of all narcotics on the narcotic administration record”.
- The Controlled Drug Shift Count Record for the A Cottage Medication Cart for August 2023 was noted to not have signatures for the “nurse off 11-7” on 8/01/2023, “nurse on and nurse off 3-11” on 08/04/2023, “nurse off 3-11 and nurse on 11-7” on 08/11/2023, “nurse on 11-7” on 08/13/2023 and “nurse off 11-7” on 08/14/2023.
- The Controlled Drug Shift Count Record for the B Cottage Medication Cart for August 2023 was noted to not have signatures for the “nurse on 11-7” 11- Shift on 8/13/2023, “nurse off 11-7” 7-3 Shift on 8/14/2023, “nurse on 11-7” 11- Shift on 8/14/2023, and “nurse off 11-7” on 7-3 Shift on 8/15/2023.
Plan of correction
DON will ensure that all signature on and off shifts are completed daily and monitored and audited for completion.
22VAC40-73-860-I
Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area.
Evidence
- A can of Comet Cleaner and a can of Xcelente Multipurpose Cleaner was observed sitting out on the glove box that was hanging on the wall in the bathroom across from room H-11 on the facility safe, secure unit.
- The first door to the right of the stairway in the lower level/basement hallway was noted to be opened and the room contained a bottle of Fresh Laundry Sanitizer, a bottle of Great Value Glass Cleaner and a bottle of Clean by Peroxy All Purpose Hydrogen Peroxide Based Cleaner. A door leading into a storage area was also open and the room contained a bottle of Consume Mirco-Muscle General Purpose Degreaser.
- The second door to the right of the stairway in the lower level/basement hallway was noted to be unlocked and the room contained a bottle of Clean by Peroxy All Purpose Hydrogen Peroxide Based Cleaner, a bottle of Chlor-Glo Bleach and a bottle of Hoover Permanent Stain Removal.
- The maintenance room to the left of the stairway in the lower level/basement hallway was noted to be opened and the room contained a bottle of Harvey’s Thread Cutting Oil, a can of Mainline CPVC & PVC Plastic pipe cement, several cans of Oatey Purple Primer and Oatey Stain-Free Plumbers Putty.
Plan of correction
ED/DON/Nursing staff will ensure that all cleaning supplies are stored appropriately. Maintenance will ensure that all doors in basement is closed and locked at all times and appropriate locks are placed on doors to basement as recommended.
22VAC40-73-70-A
Based on resident record review and collateral documentation, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
- The record for resident 10 contains a facility staff note, dated 07/14/2023 at 6:45AM, that the resident was brought back to the facility by Collateral 1 and that the resident had wandered off facility property with the intention of finding his wife. The note also states that once the resident was brought back to the facility, he was given a PRN anxiety medication, shown to his room multiple times throughout the evening and that the resident finally settled down around 12:00AM.
- Incident report provided by Collateral 1 to the licensing inspector states that on 07/13/2023 from 8:31PM until 9:00PM Collateral 1 responded to the 900 block of College Street Bedford, Virginia 24523 in reference to a suspicious male that was walking in the area. Upon Collateral 1’s arrival, Collateral 1 noted that the individual appeared confused and was making statements that were not making sense. The resident had several pieces of paper in his pockets with phone numbers along with a single key with a key chain that contained the facility’s name and Collateral 1 took the individual to the facility. Collateral 1 met with facility staff that identified the individual as a resident at the facility.
- The aforementioned information was not reported to the regional licensing office.
Plan of correction
ED/DON will in-service nursing staff to correctly document. DON will ensure and monitor daily for accuracy. Residents H&P states resident is able to self-preservation on admission. Resident was re-assessed an appropriate documentation was completed the date of this inspection; resident was placed on secured unit per MD orders on 8.24.2023
22VAC40-73-880-C
Based on observation during a tour of the facility physical plant, the facility failed to ensure that the temperature in all areas used by residents does not exceed 80 degrees Fahrenheit.
Evidence
- During a walk-through of the facility’s assisted living building with staff 7 during on-site inspection on 08/16/2023, the licensing inspector (LI) and staff 7 recorded the following temperatures that exceeded 80 degrees Fahrenheit: 83 degrees Fahrenheit in the walkway/hall outside of the entrance of C cottage at 10:33AM; 81 degrees Fahrenheit in the walkway/hall outside of the entrance into D cottage at 10:33AM; 80.5 degrees Fahrenheit in the walkway/hall outside of the entrance into B cottage at 10:33AM; 83 degrees Fahrenheit in the library at 10:30AM; 81.5 degrees Fahrenheit in the activities room/dining room beside A/B/C/D cottages at 10:30AM; and 87 degrees Fahrenheit in the sitting area/common area between F/G cottage and E cottage near the elevator at 10:39AM.
Plan of correction
Facility has gotten A/C working.
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated as needed for a significant change of a resident’s condition.
Evidence
- Resident 10 was admitted to the facility on 05/22/2023. The record for resident 10 contains a facility staff note, dated 06/06/2023 at 4:30PM, that the resident was pacing down halls and calling his wife over and over; resident was provided with one-on-one from staff and an additional facility staff note, dated 06/22/2023 at 11:30PM, indicated that the resident was trying to leave the facility out the front door, the resident was agitated, cursed at three staff members who were trying to redirect him and that staff assisted him back into the facility and to his room.
- A physician progress note, dated 06/20/2023, included documentation that facility staff had reported to the physician that the resident had increased pacing for the past three days.
- The record for resident 10 also contains a facility staff note, dated 07/14/2023 at 6:45AM, that the resident was brought back to the facility by Collateral 1 and that the resident had wandered off facility property with the intention of finding his wife. The note also states that once the resident was brought back to the facility, he was given a PRN anxiety medication, shown to his room multiple times throughout the evening and that the resident finally settled down around 12:00AM. Additional information provided by Collateral 1, indicated that they were made aware of a suspicious male in the 900 block of College Street Bedford, Virginia through a report at 8:31PM on 07/13/2023 and identified the male as living at the facility. Collateral 1 brought the resident to the facility and facility staff identified the resident as a resident of the facility.
- A physician progress note, dated 07/18/2023, included documentation that the resident was being seen by the physician at request of facility staff as the resident had recently left the facility late in the afternoon/early evening, had to be returned by the police and that staff had reported that the resident’s confusion worsens with an increase in pacing and wandering daily after 4:00PM and that the resident has been experiencing an increase in insomnia.
- The ISP in the record for resident 10, dated 05/23/2023, did not include information regarding the resident’s wandering, pacing and exit-seeking behaviors.
Plan of correction
DON will ensure that all ISP;s are updated as needed.
22VAC40-73-660-A-1
Based on observations of the facility physical plant, the facility failed to ensure that storage areas for medications were locked.
Evidence
- At approximately 11:14AM on the day of inspection, staff person 1 left the nursing station at the end of the hallway by A cottage to locate a resident that was due to receive medications. Two licensing inspectors observed that the medication refrigerator located in the nursing station was left unlocked. The refrigerator contained a Novolog Insulin vial for resident 8, a Lantus Insulin vial for resident 15, 2 boxes of Basaglar Insulin Kwik Pens for resident 16, and a bottle of Lorazepm Intensol Oral Concentrate for resident 17.
Plan of correction
DON will in service all nursing staff to close the nursing station door when leaving even if the license inspector or any other staff are in the office.
22VAC40-73-660-B
Based on observations of the physical plant and resident record reviews, the facility failed to ensure that the medications kept in resident’s rooms were stored in an out of sight location in the resident’s room and only for residents who have been assessed as capable of self-administering their own medications.
Evidence
- On 08/16/2023 at approximately 9:22AM, two licensing inspectors (LI’s) observed a container of Hempvana Pain Relief Cream Trolamine Salicylate 10% sitting out on the dresser in the room for resident 8. The uniform assessment instrument (UAI), dated 04/15/2023, has documentation that resident 8’s medications are administered to them by a lay person and the box below indicates that facility registered medication aids (RMAs) and licensed practical nurses (LPNs) administer the medications. The record for resident 8 did not contain a physician’s order for Hempvana Pain Relief Cream Trolamine Salicylate 10%. Staff person 3 confirmed that the facility administers the resident’s medication.
- On 8/16/2023 at approximately 9:33AM, two LIs observed a bottle of H Chlor 12 .125% Sodium Hypochlorite solution in the bathroom on an open shelf in the room of resident 7. The UAI, dated 8/1/2023, has documentation that resident 7’s medications are administered to them by a lay person and the box below indicates that facility registered medication aides (RMAs) and licensed practical nurses (LPN) administer the medications. The record for resident 7 did not contain a physician’s order for the H Chlor 12 .125% Sodium Hypochlorite solution. Staff person 3 confirmed that the facility administers the resident’s medication.
- On 8/16/2023 at approximately 9:38AM, two LIs observed a tube of Clobetasol Propionate Cream USP 0.05% and a tube of Equate Athlete’s Foot Terbinafine Hydrochloride 1% on the nightstand near the bed in the room of resident 5. The UAI, dated 4/1/2023, has documentation that resident 5’s medications are administered to them by a lay person and the box below indicates that facility registered medication aides (RMAs) and licensed practical nurses (LPN) administer the medications. The record for resident 5 did not contain a physician’s order for both Clobetasol Propionate Cream USP 0.05% and Equate Athlete’s Foot Terbinafine Hydrochloride 1%. Staff person 3 confirmed that the facility administers the resident’s medication.
- On 08/16/2023 at approximately 9:46AM, two LIs observed a bottle of CVS Health 8 HR Muscle Aches & Pain Acetaminophen Extended Relief 650mg and a bottle of Max Strength Aspercreme with 4% Lidocaine Pain Relief Liquid sitting out on a table beside a chair in the living room for resident 6. The UAI for resident 6, dated 03/01/2023, contains documentation that the resident’s medications are administered to them by a layperson and the box below indicates that facility registered medication aids (RMA’s) and LPN’s administer the medications. The record for resident 6 did not contain a physician’s order for the aforementioned medications. Staff 3 confirmed in an interview that the facility administers resident 6’s medications.
Plan of correction
ED/DON/Nursing staff will ensure and conduct weekly room sweeps to ensure that resident of families have not brought in any OTC medications that are not on their MAR. DON will obtain orders as needed for these.
22VAC40-73-1040-B
Based on resident record review, staff and resident interview, and observation, the facility failed to ensure that there are protective devices on the bedroom windows of residents with serious cognitive impairments and on windows in common areas accessible to these residents to prevent the windows from being opened wide enough for a resident to crawl through.
Evidence
- The record for resident 10, admitted to the facility on 05/22/2023, contains documentation that the resident was a patient in the hospital from 05/01/2023 until 05/22/2023.
- Notes from Collateral 2 includes the following information regarding the resident: resident has a history of two traumatic brain injuries (TBI) the first being in 2006 and had noticeable memory loss which included getting lost in an area of town where he is very familiar with surroundings and a second in 2021 where the resident began to show more personality changes, more irritability, low frustration tolerance, more aggressive at intervals and at one time experienced visual hallucinations of people in his house and unknown car in his driveway; 05/03/2023, resident is oriented only to self and does not know why he is in the hospital; 05/05/2023, resident is oriented only to self and when asked where he was at the resident responded that he was at the counter (nurses’ station) and supposed to meet some people to go elsewhere and that he has to help do some carpentry work; 05/06/2023, resident is oriented only to self and knows he is at hospital; however, the resident had no idea why he was at the hospital; 05/07/2023, resident is oriented only to self and 05/08/2023, resident is orientated only to self. In addition, documentation in the record for resident 10 from Collateral 2 stated on 05/10/2023 that the resident will need placement in an appropriate memory care unit. The documentation from Collateral 2 that includes this information contains a fax time stamp of 05/22/2023 which is the day that the resident was admitted to the facility.
- The uniform assessment instrument (UAI) for resident 10, with an assessment date of 05/16/2023 and a reassessment date of 06/08/2023, indicates that the resident is disoriented to all spheres (person, place, and time) some of the time. The individualized service plan (ISP) for the resident, dated 05/23/2023, indicates that the resident is disoriented to all spheres some of the time.
- The record for resident 10 contains documentation that the resident started receiving occupational therapy (OT) on 06/07/2023 and that facility staff had reported to OT that the resident is having trouble finding his room and locating necessary places throughout the facility. OT notes for the resident indicate that the goals of OT for the resident would be that the resident will be able to locate his room with stand-by-assist and visual cues as needed demonstrating good safety and that the resident will be able to locate his room and all necessary facilities such as bathroom and dining room, throughout the facility using visual aides as needed demonstrating good safety. (see additional documentation)
Plan of correction
Resident at the time of inspection was re-assessed and placed on secured unit per MD orders.
DON will ensure that all ISP’s are updated as needed for any LOC.
22VAC40-73-860-J
Based on observations of the facility physical plant, the facility failed to ensure that residents who keep their own cleaning supplies or other hazardous materials in their rooms stored them in an out-of-sight place so that they are not accessible to other residents.
Evidence
- The door to room A-102 was noted to be opened on the day of inspection and a can of Lysol Spray was observed sitting out on the sink in the bathroom. The resident who resides in this room was not present in the room at the time of this observation.
- The door to room A-206 was noted to be opened on the day of inspection and a can of Lysol Spray, a can of Airlift Air Freshner, a can of Renuzit Dream Garden Air Freshner and a bottle of Febreeze were observed sitting out on the shelf in the bathroom. The resident who resides in this room was not present in the room at the time of this observation.
- The door to room D-203 was noted to be opened on the day of inspection and a container of True Living Disinfectant Wipes was observed sitting out on the windowsill of the living room. The resident who resides in this room was noted to be in a separate room sleeping at the time of this observation.
Plan of correction
ED will send communication to all residents on AL that all sprays, etc are stored and put away at all times.
August 16, 2023Complaint survey0 violations
Inspection dates
08/16/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint
Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/16/2023 8:45AM until 3:45PM
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 07/14/2023 regarding allegations in the area(s) of: personnel and resident care and related services
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.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 11, 2023Complaint survey1 violation
Inspection dates
07/11/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/11/2023 12:06PM until 1:30PM
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 07/06/2023 regarding allegations in the areas of: resident care and related services and buildings and grounds
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: buildings and grounds
A violation notice was 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-880-C
Based on observations during a tour of the physical plant, the facility failed to ensure that the temperature in all areas used by residents does not exceed 80 degrees Fahrenheit.
Evidence
- During a walk-through of the facility’s assisted living building between 12:54PM and 1:13PM, the licensing inspector (LI) and staff 1 recorded the following temperatures that exceeded 80 degrees Fahrenheit: 81 degrees Fahrenheit in the walkway/hall outside of the entrance into B cottage and C cottage; 82 degrees Fahrenheit in the library, the bottom level of C cottage, and in room C-1; 82.5 degrees Fahrenheit in the activities room and in the walkway/hall outside of the entrance into D cottage; 83 degrees Fahrenheit in the walkway/hall outside of the entrance into E cottage and 87.5 degrees Fahrenheit in the sitting area/common area between F/G cottage and E cottage near the elevator.
Plan of correction
Facility will ensure that all Common areas/halls are under 80 degrees
June 28, 2023Complaint survey0 violations
Inspection dates
06/28/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
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: 06/28/2023 8:55AM until 10:06AM in conjunction with the local adult protective services office
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by VDSS Division of Licensing on 06/01/2023 regarding allegations in the area(s) of: personnel and resident care and related services
An exit meeting will be conducted to review the inspection findings.
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 Jennifer Stokes, Licensing Inspector at 540.589.5216 or by email at Jennifer.stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 31, 2023Complaint survey0 violations
Inspection dates
05/31/2023, 06/29/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
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: 05/31/2023 8:45AM until 2:30PM, 06/07/2023 2:30PM until 4:30PM and 06/29/2023 2:30PM until 4:00PM in conjunction with local adult protective services.
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 05/24/2023 regarding allegations in the area(s) of: personnel and resident care and related services
The evidence gathered during the investigation did not support the (allegation(s)/self-report) 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 Jennifer Stokes, Licensing Inspector at 540.589.5216 or by email at Jennifer.stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 31, 2023Inspection8 violations
Inspection dates
05/31/2023
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 of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 8:45AM until 2:30PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident record review, staff interview and document review, the facility failed to ensure that medications were administered in accordance with physicians’ instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing (VBON).
Evidence
- The current medication aide curriculum revised by the Virginia Board of Nursing in 2022 contains the following documentation on page 53: “Non-Insulin Injections a. medication aides may not administer pursuant to 18VAC90-60-110(B)(5)”.
- The May 2023 medication administration record (MAR) for resident 5 contains documentation that the resident receives Trulicity, a non-insulin injection, once a week.
- The May 2023 MAR indicates that the resident received a Trulicity injection on 05/03/2023, 05/10/2023, 05/17/2023 and 05/24/2023; however, the injections were all administered by registered medication aides (RMAs). Interview with staff 6 confirmed that this is accurate.
Plan of correction
DON will ensure/educate all RMA's on all non-insulin protocols
22VAC40-73-870-A
Based on observations of the facility physical plant, the facility failed to maintain the exterior and interior of the building in good repair.
Evidence
- The front area of the building above the green awnings was noted to have an area of wall damage.
- The carpet in the hallway outside of the library and the A through D cottages was noted to have multiple stains.
- The carpet in the hallway outside of E cottage was noted to have areas of staining under the windows and in the middle of the hall.
- The carpet in the hallway outside of room G-102 was noted to have staining.
- The carpet in the hallway in F cottage outside of room F-102 was noted to have areas of staining.
- The carpet outside the main doors at the threshold to the dining room near the bulletin board was noted to be stained.
Plan of correction
The facility will obtain professional carpet cleaning services to remove stain from carpet.
22VAC40-73-700-2
Based on observations of the facility physical plant, the facility failed to post a “No Smoking-Oxygen in Use” sign in all rooms where oxygen is in use.
Evidence
- An oxygen concentrator was observed in use by the resident who resides in room B-205 on the day of inspection. A “No Smoking-Oxygen in Use” sign was not posted for this room.
Plan of correction
ED/DON will ensure that all oxygen in use signage is in place.
22VAC40-73-450-C
Based on resident record review, the facility failed to ensure individualized service plans (ISPs) were completed as required.
Evidence
- The record for resident 5 contains a signed physician’s order, dated 01/03/2023, for the resident’s diet to be upgraded to mechanical soft and an additional signed physician’s order, dated 01/17/2023, for the resident to continue with the mechanical soft diet and request to allow hard-boiled eggs.
- The ISP for resident 5, dated 07/28/2022, contains documentation that the resident is to be receive a regular diet and does not include information about a mechanical soft diet. This was also noted by staff 6.
Plan of correction
DON/DSD will ensure that all Diet orders are communicated during stand up to ensure accuracy for all ISP's
22VAC40-73-860-I
Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area.
Evidence
- During on-site inspection, two licensing inspectors (LIs) noted in the facility’s safe, secure unit a can of Air Lift Tropical Air Fresher sitting out in the bathroom across from room H-111 and the sink in the bathroom across from room H-124 was unlocked and contained a can of Spartan TB-Cide Quat Cleaner and a container of Clorox Hydrogen Peroxide Disinfectant wipes.
Plan of correction
ED/DON will ensure that all cleaning supplies are properly locked in all cabinets
22VAC40-73-250-D
Based on staff record review, the facility failed to ensure that prior to coming in contact with residents that each staff person on or within seven days prior to the first day of work at the facility submitted the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as
Evidence
- d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. EVIDENCE: The date of hire for staff persons 1, 2, 3 and 4 is 03/18/2023; however, the TB assessments in the records for these staff persons were all dated 04/10/2023.
Plan of correction
ED/BOM will ensure that all TB screening are completed within 7 days of hire
22VAC40-73-290-B
Based on observations of the facility physical plant, the facility failed to follow their person in charge posting procedures.
Evidence
- At approximately 8:45AM on the day of inspection, the person in charge posting was observed to contain the names of staff in charge for the previous day (05/30/2023).
Plan of correction
Security will maintain person in charge posting by 6AM daily
22VAC40-90-40-B
Based on staff record review, the facility failed to ensure that criminal history record reports were obtained on or prior to the 30th day of employment for each employee.
Evidence
- Staff 1 was hired on 03/18/2023. The Virginia State Police (VSP) criminal record exchange document for staff 1 indicates that the results of the search were not received until 05/16/2023.
- Staff persons 7 and 8 were hired on 03/18/2023. The VSP criminal record exchange documents for staff persons 7 and 8 indicate that the results of the search were not received until 05/31/2023 for both staff.
- Staff persons 9, 10 and 11 were hired on 03/18/2023; however, the VSP criminal record exchange documents for these staff persons provided during on-site inspection on 05/31/2023 contained documentation that the status of the searches is that “transaction is being processed” indicating that results have not yet been received.
Plan of correction
ED/BOM will ensure that all Background checks are Completed per state Requirements.
December 22, 2022Inspection3 violations
Inspection dates
12/22/2022
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: Initial
Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/22/2022 10:00AM until 12:45PM
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-870-A
Based on observation during a tour of the buildings, the facility failed to maintain and keep clean the interior and exterior of the building.
Evidence
- During on-site inspection on 12/22/2022, it was noted by the licensing inspector that the doors at the front entrance of the facility were damaged and not operating correctly.
- During on-site inspection on 12/22/2022, it was confirmed that the facility’s sprinkler system and fire alarm system have not been maintained to meet current required guidelines (Collateral 1).
- Multiple windows located in both dining rooms in the facility’s safe, secure unit were noted to be unclean.
- The stucco on the front of the building was chipped in various areas on the left and right sides of the main entrance into the building along with multiple areas of a dark colored substances along the outside of the building.
- The top of the wall and ceiling in the back left corner of the dining/activity room was noted to have chipping paint.
- Numerous stains were observed on the carpet in front and down the hallways in A, B, C, D, E, F, and G cottages as well as numerous scuffs on the walls down the hallways in A, B, C, D, E, F, and G cottages.
- Numerous areas were observed of chipped paint on the walls and ceiling near and around the murals in the formal dining room.
- The exterior of the assisted living building was observed of having brown and orange stains along the bottom of the building in various locations and cracked sidewalks in various locations.
Plan of correction
1. Front entrance doors have been replaced (2-28-2023)
2. Sprinkler system and fire alarm will be maintained to meet required guidelines (2-28-2023)
3. Windows will be cleaned as needed (3-31-2023)
4. The stucco in front of the building in spots of building will be cleaned as best as possible and touched up with paint (5-31-2023)
5. Ceiling in activity room will be painted so there is no chipped paint (4-30-2023)
6. Stains in carpet in all cottages will be cleaned and wall paint in all cottages will be maintained (5-31-2023)
7. Dining room paint will be maintained and chips will be fixed (5-31-2023)
8. Exterior building brown and orange stains along the bottom will be cleaned and touched up with paint (5-31-2023)
22VAC40-73-960-A
Based on staff interview, the facility failed to ensure its written plan for fire and emergency evacuation that is to be followed in the event of a fire or other emergency has been approved by the appropriate fire official.
Evidence
- Interview with staff 1 during on-site initial inspection on 12/222/2022 revealed that the facility’s written plan for fire and emergency evacuation has been submitted to the appropriate fire official; however, the aforementioned plan has not yet been approved by the fire official.
Plan of correction
Fire and emergency evacuation will be followed and approved by appropriate official.
22VAC40-73-950-A
Based on document review and interview, the facility failed to ensure there was documentation of initial contact with the local emergency coordinator to determine the requirements of the standard.
Evidence
- Interview with staff 1 during on-site initial inspection on 12/22/2022 confirmed that there has been no initial contact with the local emergency coordinator to determine local disaster risks, communitywide plans to address different disasters and emergency situations, and assistance, if any, that the local emergency management office will provide to the facility in an emergency.
Plan of correction
Facility will contact the emergency coordinator to plan and address emergency situations