9
Inspections
On record
4
With violations
Visits that cited something
5
Clean visits
Nothing cited
12
Violations cited
Individual findings
12
Standards cited
Distinct rules
2
Complaint visits
Prompted by a complaint

Spring Oak Warrenton was inspected 9 times between December 16, 2022 and April 22, 2026 by the Virginia Department of Social Services. 4 of those visits ended with violations cited and 5 with none. Across that history VDSS cited 12 violations under 12 distinct standards. 2 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
06/30/2026
Administrator
Karen Sanchez
Licensing inspector
Patricia Koval
Inspector phone
(804) 621-6046
Approved for
Assisted Living · Non-Ambulatory

Inspection History

9

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

April 22, 2026Inspection4 violations
Inspection dates
04/22/2026
Areas reviewed
22VAC40-73 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 Building and Grounds22VAC40-73 Emergency Preparedness22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 Sworn Statement
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: 4/22/2026, 9:00am to 4:00pm 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: 19 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: The LI observed residents participating in activity programs and eating meals. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-290-B
Based on observation and staff interview, the facility failed to post the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public.
Evidence
  1. During the inspection entrance tour on 4/22/2026, the LI observed a sign on the wall titled Designated Person in Charge; however there was no staff person’s name listed.
  2. Staff 3 acknowledged the Designated Person in Charge sign did not include a staff person’s name.
  3. Picture evidence.
Plan of correction
Not published by VDSS.
22VAC40-73-450-C
Based on resident record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) contained a description of identified needs based upon the uniform assessment instrument (UAI).
Evidence
  1. Resident 2, admitted 9/20/2023, had a Uniform Assessment Instrument (UAI) on file dated 2/20/2026 that indicated resident 2 needed mechanical help and supervision with bathing and supervision with dressing. The UAI also indicated resident 2 was verbally abusive at times and had occasional hallucinations. 2. The ISP for resident 2 dated 2/20/2026 did not include resident 2’s need for assistance with bathing or dressing and did not address resident 2’s behaviors of verbal abuse or hallucinations.
  2. Staff 3 acknowledged these needs were not addressed on the ISP for resident 2.
Plan of correction
The Executive Director and Director of Wellness will ensure all residents’ ISPs and UAIs are consistent and accurately reflect each resident’s needs.
22VAC40-73-680-I
Based on resident record review and staff interview, the facility failed to ensure the medication administration record (MAR) included the diagnosis, condition, or specific indications for administering a drug or supplement.
Evidence
  1. Resident 1, admitted 4/17/2026, had an April 2026 MAR on file that included an order written 4/17/2026 that stated: Lorazepam 0.5 mg tablet, take one table by mouth rarely as needed as directed but did not include a diagnosis.
  2. Resident 2, admitted 9/20/2023, had an April 2026 MAR on file that stated: Ariprprazole 1 mg/ml soln (ordered 4/2/2026),take 5ml (5mg) by mouth every day with any liquid/juice; risperidone inj 50mg ER (ordered 3/9/2026), inject 50mg intramuscularly every 2 weeks; lorazepam 2mg/ml conc. (ordered 3/20/2026), take 0.25ml (5mg) by mouth at bedtime at 7:30pm; ingrezza 40mg capsule (ordered 3/28/2026), take 1 capsule by mouth every day; abilify maintena 400mg syringe (ordered 4/20/2026), inject 400mg intramuscularly every 28 days. All medications, aforementioned, did not list a diagnosis or reason for the medications for resident 2.
Plan of correction
All MARs will be reviewed by the Director of Wellness to ensure each includes a documented diagnosis.
22VAC40-73-970-A
Based on facility record review and staff interview, the facility failed to ensure fire drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51).
Evidence
  1. During inspection on 4/22/2026, the LI asked staff 3 for fire drills since last inspection on 5/25/2025. There were no fire inspection reports available for June 2025, July 2025 or September 2025, or March 2026.
  2. Staff 3 acknowledged there were no fire inspection reports available for June 2025, July 2025, September 2025 or March 2026.
Plan of correction
The Executive Director and Plant Operations Coordinator will ensure fire drills are conducted and documented monthly.
November 5, 2025Inspection0 violations
Inspection dates
11/05/2025
Areas reviewed
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: 11/5/2025 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 8/29/2025 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 25 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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: 1 Observations by licensing inspector: The LI observed residents in the dining room preparing to eat lunch, Additional Comments/Discussion: 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
November 5, 2025Inspection0 violations
Inspection dates
11/05/2025
Areas reviewed
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: 11/5/2025 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 8/1/2025 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 25 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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: 1 Observations by licensing inspector: Additional Comments/Discussion: LI observed residents in the dining room preparing to eat lunch. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
May 21, 2025Inspection4 violations
Inspection dates
05/21/2025
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuilding and GroundsEmergency PreparednessBackground Checks for Assisted Living FacilitiesSworn Statement
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: 5/21/2025 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: 20 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: The LI observed residents participating in activity programs and eating breakfast and lunch. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-190-C
Based on staff record review, observation and staff interview, the facility failed to train the staff member prior to being placed in charge.
Evidence
  1. During entrance of inspection on 5/21/2025, the LI observed a posted sign titled ‘Designated Person in Charge’ in the lobby of the facility with staff 1’s name listed.
  2. During staff record review of staff 1, the LI did not see documented training for designated direct care staff person in charge.
  3. LI asked staff 4 if there was documented training for designated direct care staff person in charge and she could not locate the training.
  4. Picture evidence
Plan of correction
All Registered Medication Aides will undergo 'Person in Charge' training and will sign off of declination of training received to be placed in employee files. Training to be reviewed and updated annually
22VAC40-73-710-D
Based on observation and staff interview, the facility failed to monitor the condition of a resident with restraints, which includes checking on the resident at least every 30 minutes.
Evidence
  1. During entrance tour the LI observed resident 2 in bed with both half-rails in the up position at 10:00am, and at 12:00pm and at 1:54pm.
  2. The LI asked staff 2 for documented 30 minute checks for resident 2 and staff 2 stated there were not 30 minute checks by staff for today.
Plan of correction
A 30-minute check form will be created and utilized for residents that are in bed both half-rails in place if the resident is not able to effectively demonstrate ability to put down half-rails without assistance. Checks will begin immediately upon usage of both rails and will continue every 30 minutes until removed or the resident is out of bed. Documentation to be maintained in wellness office for all applicable residents.
22VAC40-73-210-D
Based on staff record review, the facility failed to ensure staff received 12 hours of annual training relevant to the population in care.
Evidence
  1. Since 04/02/2024, staff 1 (hired 12/30/2022) had 7.5 hours of documented training.
Plan of correction
All staff members to complete mandated annual training to total 12 hours by 12/31/2025. Additional training to be completed per job role and to be maintained in employee file
22VAC40-73-980-H
Based on observation and staff interview, the facility failed to ensure the availability of at 48 hours of drinking water.
Evidence
  1. During tour of the kitchen, the LI asked to see the emergency food and water. Staff 4 stated there was no emergency water on site.
Plan of correction
Adequate emergency supply water to be purchased and maintained to ensure appropriate amounts are maintained for all residents for a 48 hour period. Emergency water and food to be checked monthly for adequate amounts and expiration dates. Documentation will be updated monthly and maintained in Dietary Director Office.
January 9, 2025Complaint survey0 violations
Inspection dates
01/09/2025
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionResident Care and Related Services
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/9/2025 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: 18 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: LI observed residents participating in activity programs and eating lunch.. Additional Comments/Discussion: 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
June 24, 2024Inspection2 violations
Inspection dates
06/24/2024
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuilding and GroundsEmergency PreparednessBackground Checks for Assisted Living FacilitiesSworn Statement
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: 06/24/2024-06/25/2024, 8:40am-3:00pm 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: 14 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing Inspector observed residents eating breakfast and lunch on both days of the inspection, and observed medications being administered to residents. Additional Comments/Discussion: An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-660-A
Based on observation, the facility failed to ensure medications were locked when unsupervised.
Evidence
  1. Upon arriving at the facility to start the inspection on 6/24/2024, the Licensing Inspectors observed the medication cart stationed in the lobby unlocked and unattended.
Plan of correction
ED/DON to in-service all RMA’s on med management plan
22VAC40-73-680-B
Based on observation, the facility failed to ensure medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administer to the resident.
Evidence
  1. Upon arriving at the facility, at the start of the inspection, the Licensing Inspectors observed the medication cart stationed in the lobby unlocked, and in the top drawer of the cart were loose medications in a paper cup. The cart was not attended, and medications were not being administered at the time.
Plan of correction
ED/DON to in-service on med management plan
June 24, 2024Complaint survey2 violations
Inspection dates
06/24/2024
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionResident Care and Related ServicesResident Accommodations and Related Provisions
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: 06/24/2024 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: 14 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing Inspector observed residents eating breakfast and lunch. Additional Comments/Discussion: 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 and Resident Accommodations and Related Provisions. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-680-C
Based on resident record review, the facility failed to administer medication not later than one after the facility’s standard dosing schedule.
Evidence
  1. Resident 1’s May 2024 Medication Administration Record indicates the following medication were administered late: Eliquis 5mg tablet scheduled for 8:00am was administered late on 5/3/2024 at 9:03am, 5/4/2024 at 9:28am, 5/10/2024 at 9:38am, 5/15/2024 at 9:14am, 5/21/2024 at 9:21am and 5/25/2024 at 9:07am, Bupropn HCL tab 150mg XL scheduled for 8:00am was administered late on 5/3/2024 at 9:02am, 5/4/2024 at 9:28am, 5/10/2024 at 9:38am, 5/15/2024 at 9:15am, 5/21/2024 at 9:20am and 5/25/2024 at 9:07am, Duloxetine 30mg capsule scheduled for 8:00am was administered late on 5/3/2024 at 9:03am, 5/4/2024 at 9:28am, 5/10/2024 at 9:38am, 5/15/2024 at 9:14am, 5/21/2024 at 9:20am and 5/25/2024 at 9:07am, Valsartan 320mg tabs scheduled for 8:00am was administered late on 5/3/2024 at 9:04am, 5/4/2024 at 9:30am, 5/10/2024 at 9:39am, 5/15/2024 at 9:14am, 5/21/2024 at 9:21am and 5/25/2024 at 9:07am, Antacid 500mg assorted flav scheduled for 8:00am was administered late on 5/3/2024 at 9:03am, 5/4/2024 at 9:27am, 5/10/2024 at 9:38am, Lidocaine 4% patch (OTC) scheduled for 8:00am was administered at 9:27am, Amlodipine tab 10mg scheduled for 8:00am was administered late on 5/10/2024 at 9:38am, and on 5/15/2024 at 9:15am.
  2. Resident 2’s May 2024 Medication Administration Record indicates the following medication were administered late: Levothyroxine Sod 50mcg tab scheduled for 5:30eam was administered on 5/10/2024 at 6:36am, 5/11/2024 at 6:33am 5/12/2024 at 6:33am and on 5/15/2024 at 6:37am, Mucus Relief tab 600mg ER scheduled for 8:00am was administered on 5/10/2024 at 9:57am, Allopurinol 100mg tablet scheduled for 8:00am was administered on 5/18/2024 at 9:12am, Alprazolam tab 0.25mg scheduled for 8:00am was administered on 5/18/2024 at 9:09am, Eliquis 5mg tablet scheduled for 8:00am was administered on 5/18/2024 at 9:11am. The following medications were scheduled on 5/18/2024 at 8:00am: Bisoprolol Fum 10mg tablet administered at 9:11am, Furosemide 20mg tablet administered at 9:12am, Myrbetriq 25mg tablet 7.5mg administered at 9:12am, Potassium Chlor 20meq tablet administered at 9:26am, Prednison 5mg tablet administered at 9:26am, Azithromycin 500mg tablet administered at 9:11am and Fluticasone Prop 50mcg/ACT SPR administered at 9:11am.
Plan of correction
ED/DON will review MAR report for the previous day during stand up to ensure accuracy and all medications are administered in the timeframe of 1 hour before and/or 1 hour after. ED/DON will sign off on the MAR report daily and keep a signed copy in a binder in the ED’s office and kept for records. All RMA’s will be in-serviced on the Med Management policy.
22VAC40-73-520-I
Based on observation, review of activity schedule and staff interview, the facility failed to offer at least one hour of activities each day.
Evidence
  1. No activity programs were observed to be offered on the date inspection on 6/24/2024.
  2. Staff 2 stated the reason activity programs did not occur was the Activities Director was needed to help in the kitchen.
Plan of correction
ED/or designee will ensure that activities that are posted in the community will be performed as posted. In the event that an activity changes, ED or designee will be responsible to change it on the activity calendar to reflect corrections.
May 24, 2023Inspection0 violations
Inspection dates
05/24/2023
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesBuildings and GroundsEmergency PreparednessMixed Population
Comments
Date of Inspection: May 24, 2023 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 17 Number of records reviewed and interviews conducted- 6 records (staff and residents), 5 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents in activities. The Licensing Inspector reviewed the following at the time of inspection: pharmacy review, menus, activity calendar, fire drills, emergency preparedness documentation and health care oversight.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
December 16, 2022Inspection0 violations
Inspection dates
12/16/2022
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesBuildings and GroundsEmergency PreparednessAdditional Requirements for Facilities That Care for Adults with Serious Cognitive Impairments
Comments
Date of Inspection: December 16, 2022 Type of Inspection: Initial Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 20 Number of records reviewed and interviews conducted- 4 records, 4 interviews. The residents were observed during activities and having a meal. The Licensing Inspector was not able to review all the Standards at the time of inspection. This was an initial inspection. All documentation requested was in order. A recommendation will be made for licensure.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.