Virginia DSS · Assisted Living Facility

Spring Oak Christiansburg

📍 1140 West Main Street, Christiansburg, VA, 24068

ID 49083One Year licenseActive
19
Inspections
On record
6
With violations
Visits that cited something
13
Clean visits
Nothing cited
28
Violations cited
Individual findings
23
Standards cited
Distinct rules
11
Complaint visits
Prompted by a complaint

Spring Oak Christiansburg was inspected 19 times between December 28, 2022 and March 27, 2026 by the Virginia Department of Social Services. 6 of those visits ended with violations cited and 13 with none. Across that history VDSS cited 28 violations under 23 distinct standards. 11 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
08/08/2026
Administrator
Xxx Xxx
Licensing inspector
Crystal Henson
Inspector phone
(276) 608-1067
Approved for
Assisted Living · Non-Ambulatory

Inspection History

19

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

March 27, 2026Inspection0 violations
Inspection dates
03/27/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/27/2026 The Acknowledgement of Inspection form was NOT signed and left at the facility for each date of the inspection. The facility was not open at this time due to a fire and reconstruction of the facility. Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 0 Observations by licensing inspector: 0 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 Crystal B. Henson, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@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 10:00AM 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 03/06/2025 regarding allegations in the area of: resident care and related services 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 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 14, 2025Complaint survey1 violation
Inspection dates
01/14/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT 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: 01/14/2025 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.Begin 2:00pm End: 2:38pm A complaint was received by VDSS Division of Licensing on 09/19/2024 regarding allegations in the area(s) of: resident care and accommodation. Number of residents present at the facility at the beginning of the inspection: did not gather 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: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) 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 Crystal B. Henson, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
22VAC40-73-325-A
Based on resident record review, the facility failed to complete a fall risk rating for one resident after one fall.
Evidence
  1. Resident #1 had falls documented by the facility on the following dates: 07/06/2024, 07/09/2024, 07/11/2024, and 07/15/2024. 2.The facility did not complete a fall risk rating on 07/15/2025.
Plan of correction
ED and DON will ensure that Fall risk Ratings are completed annually, and, after every fall when the residents' condition changes. [sic]
January 14, 2025Complaint survey0 violations
Inspection dates
01/14/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/14/2025 Begin: 1:00pm End: 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 on11/27/2024 regarding allegations in the area(s) of: staff/resident care/contact. Number of residents present at the facility at the beginning of the inspection: did not gather 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: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation 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 Crystal B. Henson, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 9, 2024Inspection3 violations
Inspection dates
07/09/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/09/2024 Begin: 10:45am End: 3:10pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 41 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 3 (plus 8 new employees) Number of interviews conducted with residents:2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Crystal B. Henson, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
22VAC40-73-710-C
Based on resident record review, the facility failed to ensure a physician’s order for a restraint specified the condition, circumstances, and duration under which the restraint is to be used.
Evidence
  1. Resident #2 has a physician’s order dated 07/02/2024 for “half siderails to hospital bed for safety and to aide in turning and repositioning self in bed” . This order does not address each of the above mentioned specifics according to the standards for licensed assisted living facilities.
Plan of correction
ED/DON will ensure when a physician writes an order pertaining to any DME, it will state the specified condition, circumstances, and duration under which the DME is to be used. [sic]
22VAC40-73-640-A
Based on observations made during the noon medication pass and the medication cart audit, the facility failed to implement their own plan for medication management.
Evidence
  1. The facility’s medication management plan (page 1, #4) addresses methods to ensure resident’s prescription and over the counter drugs ordered for the resident are filled and refilled in a timely manner to avoid missed doses. More specifically, 4.A of this plan states, “All orders for medications, over the counter and supplements are promptly sent to the pharmacy. Pharmacy delivers daily to ensure all new orders for medications and existing medications are present as soon as possible to prevent missed doses. If for any reason the contracted pharmacy is not available to send the required medication, back up pharmacy will fill the physician/prescriber’s orders at that time to ensure no missed does.”
  2. Resident # 1 is prescribed Pregabalin 200mg capsules, take one capsule by mouth three times daily for nerve pain per a physician’s order dated 06/10/2024
  3. According to an interview with Staff #1 and per the July 2024 MAR, (Medication Administration Record) Resident #1 missed 10 doses of Pregabalin 200mg due to the medication not being available in the facility.
Plan of correction
ED/DON will ensure that all orders for medications are sent promptly to the pharmacy. Weekly audits will be conducted to ensure all medications are in the facility at all times. [sic]
22VAC40-73-680-M
Based on observations made during the medication cart audit, the facility failed to have all medications ordered for PRN (as needed) administration available for the specific resident.
Evidence
  1. Resident #1 has a physician’s order dated 06/24/2024, for Acetaminophen 325mg tablet, take two tablets by mouth every six hours as needed for pain or fever.
  2. Staff #2 was not able to locate the Acetaminophen for Resident #1 on the medication cart. 3. During an interview with staff #1 and #2, both reported the medication was not available in the facility to the resident on the date of the inspection (7-09-2024).
Plan of correction
ED/DON will ensure that all orders for medications are sent promptly to the pharmacy. Weekly audits will be done. Back up pharmacy will be used if needed. [sic]
June 12, 2024Complaint survey0 violations
Inspection dates
06/12/2024, 07/09/2024,08/01/2024
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 BUILDINGS AND GROUND
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: 06/12/2024 Begin: 1:30am End: 5:15 am 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: not gathered 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: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Crystal B .Henson, Licensing Inspector at276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 4, 2024Inspection0 violations
Inspection dates
04/04/2024
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: 04/04/2024 3:15pm-3:40pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. he 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 Crystal B. Henson, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 20, 2024Inspection0 violations
Inspection dates
03/20/2024; 04/04/2024
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: 04/04/2024 2:35pm-3:15pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Crystal B. Henson, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 21, 2023Complaint survey0 violations
Inspection dates
11/21/2023
Areas reviewed
22VAC40-73 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 GROUND
Comments
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 Crystal B. Henson Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 24, 2023Complaint survey0 violations
Inspection dates
08/24/2023
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: 08/24/2023 Begin: 1:30pm End: 3:10pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: information not gathered 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: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: receipts/documents Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) 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 Crystal B. Henson Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 10, 2023Complaint survey1 violation
Inspection dates
08/10/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/10/2023 Begin: 2:35pm End: 3:20pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: did not collect information The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 17 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Crystal B. Henson Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
22VAC40-73-680-B
Based on collateral and staff interview, facility self-report, and a complaint received by the Department, the facility failed to keep medications in their pharmacy issued container, with the prescription label or directions attached, until administered to the resident. EVIDNECE: 1. The Department received a complaint on07/14/2023 regarding staff #1’s medication administration practices. 2. Per a telephone conversation on 07/14/2023 with collateral #1 she reports while she was in the facility on 05/13/2023 at approximately 5:30pm she witnessed staff #1open the medication cart to administer the evening medications and she then observed numerous medications which were pre-poured sitting in clear soufflé cups inside the medication cart. Collateral #1 states she immediately went to speak with staff #2 regarding her concerns. 3. The Licensing Inspector received a written report from the facility via e-mail on 07/17/2023 regarding staff #1. The e-mail stated staff #1 “was observed by the ombudsman (name) pre-pulling medications from her cart. ED[Executive Director] was able to verify that there was pre-pulled medication left in the cart.” 4. LI interviewed staff #2 on 08/10/2023 at the facility regarding the complaint/report. Staff #2 stated she was notified by collateral #1 that she had observed staff #1 open the medication cart to administer evening medications and collateral #1 saw numerous pre-poured medications. During this same interview with staff #2 she also stated she immediately went to staff #1 and asked her to open the medication cart. When staff #1 opened the medication cart, staff #2 witnessed numerous pre-poured medications which were in clear soufflé cups labeled with the names of residents #1 – #17 and their room numbers. 5. According to an interview with staff #2, staff #1 was asked to leave the facility until further notice and all pre-poured medications were wasted by staff #2. 6. Staff #3 was then tasked with administering all the evening medications that had not been documented on the July 13, 2023, MAR for 5:00pm and later. 7. Staff #2 stated residents #1 - #17 did not miss their dose of evening/night-time medication for July 13, 2023.
Plan of correction
ED/DON will ensure all current medication aides are education on medication policy and procedure. All medication aides will receive medication refresher. Staff #1 has been terminated from the facility and reported to nursing board. [sic]
August 10, 2023Inspection0 violations
Inspection dates
08/10/2023
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: 08/10/2023 Begin: 2:35pm End: 3:20pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 58 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: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the 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 Crystal B. Henson Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 11, 2023Inspection18 violations
Inspection dates
07/11/2023
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 IMPAIRMENTS
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/11/2023 Begin: 10:3:0am End: 4:30pm 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 Crystal B. Henson Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
22VAC40-73-870-F
Based on observations made during the tour of the building, the facility failed to have nonslip surfaces on ramps, stairways, and steps inside and outside of the building.
Evidence
  1. The nonskid surfaces on the ramp outside of room #30 are missing.
  2. The ramp near the deck off of the dining room is missing the nonskid strips.
Plan of correction
ED/Maintenance have and will replace non slid strips on all outside steps, stairwell, and ramps, this will be monitored as needed. [sic]
22VAC40-73-680-G
Based on observations made during the medication cart audit, the facility failed to have any over-the-counter medication in the original container, labeled with the resident’s name or in a pharmacy-issued container until administered.
Evidence
  1. Skintegrity wound cleanser was found on the medication cart with no name.
  2. Staff #2 stated Hospice brought it in .
Plan of correction
ED/DON will ensure all medications are labeled with resident’s name and stored in a pharmacy issued container. DON will conduct weekly cart audits. [sic]
22VAC40-73-710-D
Based on review of resident records and staff interview, the facility failed to document the usage, outcome, and checks on any residents when restraints are in use.
Evidence
  1. According to staff #3 there was no record of restraint usage, outcomes of restraint usage and no documentation of 30-minute checks for residents #4 and #9.
Plan of correction
ED/DON will ensure that floor staff document the usage, outcome, and checks on any resident with restraints by creating and auditing log for residents that have a restraint. [sic]
22VAC40-73-680-I
Based on observations made during the medication pass, the facility failed have all required information documented on the MAR (Medication administration Record)
Evidence
  1. Resident #3 has a physician’s order for Ensure three time a day with meals, this was not listed on the MAR.
  2. Resident #4 is prescribed Lorazepam 1mg daily by mouth. The MAR for 07/11/2023 did not document the medication was administered to resident #4.
Plan of correction
ED/DON will ensure that physicians orders are transcribed to the Mar by conducting a weekly audit on all new orders, and will be keeping a pending order binder to ensure all orders are followed. [sic]
22VAC40-73-230-B
Based on observations made during the tour of the building and interviews with staff, the facility failed to have a written agreement between themselves and any resident who performs staff duties.
Evidence
  1. Resident #5 was performing the scheduled activity for the morning on the day of the inspection by leading a bible lesson.
  2. In the evening, resident #8 was performing the scheduled activity on the day of inspection, he was calling out bingo numbers.
  3. According to staff #3, neither resident had a written agreement with the facility to perform those staff duties.
Plan of correction
ED has a written agreement on file for each resident that agrees, and or volunteers at the facility. The agreement includes specified duties, hours worked, and compensation. [sic]
22VAC40-73-860-I
Based on observations made during the tour of the building, the facility failed to keep cleaning supplies and other hazardous materials in a locked area.
Evidence
  1. Room #37 located downstairs was found to be unlocked and contained power tools and ceiling paint.
  2. Outside of room #36 an unsecured, unlocked cart with furniture polish was found in the hall.
Plan of correction
ED/Maintenance will ensure any hazardous materials and cleaning supplies are in a locked area and out- of- sight away from residents with cognitive impairment. [sic]
22VAC40-73-870-A
Based on observations made during the tour of the building, the facility failed to have the interior and exterior of all buildings maintained in good repair and kept clean and free of rubbish.
Evidence
  1. The floor area downstairs was very sticky where the carpet had been removed and not replaced yet. Staff stated carpet was removed at least two weeks ago.
  2. The exterior of the building was found to have an old bed frame propped up on the back corner.
  3. The floor area outside of room #36 was sticky outside in the hall area.
Plan of correction
ED/Maintenance will ensure the interior is in good repair. The flooring downstairs has been replaced. All old furnishings and fixtures are monitored during the daily walk through to ensure there is nothing that needs to be removed. [sic]
22VAC40-73-680-D
Based on observations made during the medication pass, the facility failed to administer medications in accordance with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Victoza, a non-insulin injection was being administered by a registered medication aide.
Plan of correction
ED and DON will ensure that no non-insulin injection will be administer by an RMA or administer at the facility [sic]
22VAC40-73-680-B
Based on observations made during the medication cart audit, the facility failed to ensure each individual medication properly labeled from the pharmacy.
Evidence
  1. On 05/31/2023 Resident #7 was prescribed Tresiba Flextouch 100units, inject 24 units at bedtime and Victoza18mg, inject 0.6 daily.
  2. Neither of the above mentioned medications had the directions on the packaging of the medication.
Plan of correction
ED/DON will ensure each resident’s medication is properly labeled from the pharmacy with directions on the packaging label. [sic]
22VAC40-73-860-G
Based on observations made during the tour of the building, the facility failed to maintain hot water taps available to residents within a range of 105 degrees to 120 degrees Fahrenheit.
Evidence
  1. The Licensing Inspector measured water temperature from the bathroom sink in room #9 and room #2
  2. The hot water handle was turned on and allowed to run for 120 seconds. A thermometer was placed in the running water for 120 seconds.
  3. The thermometer reading reached 71.4 degrees in room #9 and 75.3 degrees in room #2.
Plan of correction
ED/Maintenance will ensure Hot water stays within a range of 105 F to 120 F. Weekly checks will be conducted by ED/Maintenance Director to ensure compliance. [sic]
22VAC40-73-190-C
Based on record review, the facility failed to provide written documentation of duties and responsibilities to two staff members prior to being placed in charge.
Evidence
  1. Staff #1 and staff #2 both began employment on 02/08/2023.
  2. According to staff #3 both staff #s 1 and #3 serve as the person in charge from time to time at the facility.
  3. Staff #1 and staff #3’s files did not contain documentation of duties prior to being placed in charge.
Plan of correction
ED/BOM will provide going forward each staff member that’s in charge with written documentation of such duties and responsibilities. [sic]
22VAC40-73-710-C
Based on observations made during the tour of the building and resident records, the facility failed to have a physician’s order when restraints are being used.
Evidence
  1. Resident #4 was admitted to the facility on 02/17/2023. Dementia and altered mental status were listed on the 02/10/2023 physical for resident #4. The 03/17/2023 UAI (Uniform Assessment Instrument) for resident #4 documents disorientation to place and time.
  2. Resident #9 was admitted to the facility on 05/12/2021. Alzheimer’s dementia were documented on the 05/03/2021 physical for resident #4. The 01/05/2023 UAI (Uniform Assessment Instrument) for resident #4 documents wandering passive at east weekly or more and disoriented to all spheres at all times.
  3. Residents #4 and #9 was observed to have half rails on their beds. No physician’s orders were in the files for resident #4 or #9 to use the half rails.
  4. Residents #4 and #9 were interviewed while in bed and neither resident could tell the LI or show the LI how to use the bedrail or what the bedrail was for, making this a restraint.
Plan of correction
ED/DON will ensure that any resident that has a restraint or any DME device that can be use as a restraint will have a physician’s written order the specifies the condition, circumstance, and the duration under the restraint is to be use. [sic]
22VAC40-73-520-I
Based on observations made during the tour of the building, the facility failed to follow the written schedule of activities which was posted for July 2023.
Evidence
  1. On 07/11/2023 at 10:00am the activities calendar listed “sing-a-long” as the scheduled activity.
  2. At 10:15 am this activity was not taking place.
Plan of correction
ED/Activity’s Director will ensure that Activities are conducted as planned. If an activity is rescheduled or changed it will be noted on the Calendar. [sic]
22VAC40-73-100-C-1
Based on observations made during the medication cart audit, the facility failed to adhere to their infection control policy.
Evidence
  1. Resident #5’s glucometer was not labeled with his name on it.
  2. Resident #6’s glucometer was found in a basket on another medication cart and the “house” meter was located in resident #6’s bag which stores his glucometer.
Plan of correction
ED/DON will ensure all glucometers are labeled with residents names and stored in the medication cart designated for that resident. [sic]
22VAC40-90-40-B
Based on staff record review, the facility failed to obtain the criminal history record report on or prior to the 30th day of employment for three employees.
Evidence
  1. Staff #4 began employment on 05/09/2023, on 07/11/2023 the results of the background check had not been received.
  2. Staff #5 began employment on 05/15/2023, on 07/11/2023 the results of the background check had not been received.
  3. Staff #6 began employment on 04/18/2023, on 07/11/2023 the results of the background check had not been received.
Plan of correction
ED/BOM will ensure that all staff members will have a criminal history record within their 30th day of employment [sic]
22VAC40-73-680-M
Based on observations made during the medication pass, the facility failed to have medications ordered for PRN (as needed) administration available and properly labeled for the specific resident and properly stored at the facility. EIDENCE: 1. Resident #4 is prescribed one can of Ensure three times daily as needed. This medication was not available to the resident. 2. Resident #7 is prescribed Hydralazine 10mg every six hours by mouth as needed. This medication was not available to the resident. 3. Resident #2 is prescribed Cyclosporin .05%, instill one drop into both eyes twice daily as needed for dry eyes. This medication was not available to the resident.
Plan of correction
ED/DON will ensure all medications are labeled with the resident’s name and properly stored, and ready for administration. DON will conduct monthly cart audits. [sic]
22VAC40-73-310-H
Based on review of resident records, the facility failed to deny admission to an individual with a prohibitive condition.
Evidence
  1. Resident #1’s physical was completed by a physician on 05/03/2021. On page five of the physical “yes” is checked beside of psychotropic medications without appropriate diagnosis and treatment plan, This is a prohibitive condition.
Plan of correction
ED/DON will ensure no resident will be admitted to the facility with a prohibited condition without an appropriate treatment plan. [sic]
22VAC40-73-490-C
Based on resident record review, the facility failed to have a qualified health care professional (at a minimum a registered nurse)to complete the required health care oversight for restrained residents.
Evidence
  1. Residents #4 and #9 have half bedrails which are viewed as a restraint due to the documentation by a physician of their cognitive status.
  2. The last healthcare oversight was completed on 06/30/2023 and was completed by two LPNs (License practical nurses).
Plan of correction
ED/DON will ensure that when and if the facility uses a restraint that the health care professional that does oversight is a Registered nurse and does oversight at least every three months. [sic]
July 11, 2023Complaint survey1 violation
Inspection dates
07/11/2023
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection:07/11/2023 Begin: 9:30am End: 10:30am 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 06/26/2023 regarding allegations in the area(s) of: resident/staff interaction and medication administration Number of residents present at the facility at the beginning of the inspection: 55 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: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law: A violation notice was issued; any violation(s) not related to the complaint(s) 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. he department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Crystal B. Henson Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on staff and collateral interviews, the facility failed to administer medications consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. According to interviews conducted on 07/11/2023 with staff #2 and #3; resident #1 does not have self-administer orders for any of the medications she is prescribed. 2. Staff #2 and#3 stated the facility administers all prescribed medications to resident #1 daily. 3. Resident #1 receives the following medications at noon according to the June 2023 MAR (Medication Administration Record) and per interview with staff #2: Bupropion SR 150mg, take 1 tablet daily for depression; Citalopram 20mg, take 1.5 tablets daily for depression; Jardiance 10mg, take 1 daily for diabetes; Letrozole 2.5mg, take 1 daily for breast cancer; Losartan 50mg, take 1 daily for hypertension; and Clonazepam 0.5mg, take 1 table twice daily for anxiety. 4. Collateral #1 was sitting with resident #1 at a table located in the dining area at approximately 12:05pm on 06/26/2023. Staff #1 brought a white souffle cup containing resident #1’s noon medications and a small cup of water to the dining table where collateral #1 and resident #1 were seated. Staff #1 placed the souffle cup and the cup of water on the table and stepped away. At this time, ED/DON will ensure Register Medication Aides are trained on facility’s medication management plan. ED/DON will ensure that each Register Medication Aide will receive Medication aide refresher course and education. ED/DON will ensure Register Medication Aide who are responsible for administering medication are being supervised by doing periodic direct observation of medication administration. 07/31/2023 Colateral #1 requested staff #2 to observe the contents of the souffle cup. Per staff #2 interview it was confirmed resident #1’s noon medications were in the white souffle cup.
Plan of correction
ED/DON will ensure Register Medication Aides are trained on facility’s medication management plan. ED/DON will ensure that each Register Medication Aide will receive Medication aide refresher course and education. ED/DON will ensure Register Medication Aide who are responsible for administering medication are being supervised by doing periodic direct observation of medication administration. [sic]
April 26, 2023Complaint survey0 violations
Inspection dates
04/26/2023; 05/23/2023
Comments
Type of inspection: Complaint 04/26/2023 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/26/2023 Begin: 10:00am END: 10:30am 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 04/20/2023 regarding allegations in the area(s) of: physical plant Number of residents present at the facility at the beginning of the inspection: 51 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: 5 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) 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 Crystal B. Henson Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 26, 2023Inspection4 violations
Inspection dates
04/26/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS¿ 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES¿ 22VAC40-73 PERSONNEL¿ 22VAC40-73 STAFFING AND SUPERVISION¿ 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS¿ 22VAC40-73 RESIDENT CARE AND RELATED SERVICES¿ 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS¿ 22VAC40-73 BUILDINGS AND GROUND¿ 22VAC40-73 EMERGENCY PREPAREDNESS
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: 04/26/2023 Begin: 10:30am End: 3:54pm 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 Crystal B. Henson Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
22VAC40-73-870-A
Based on 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 and free of rubbish.
Evidence
  1. The floor of the air handler closet between resident rooms #17 and #19 was covered in dirt and dust. There also appeared to be a clump of used tissue and a disposable plastic cup in the floor of the same closet.
  2. There were several clumps of dirt and dust observed between the horizontal slats in the top portion of the door to the air handler closet between resident rooms #17 and #19.
  3. There was dust observed between the slats in the air filter grille located in the lower portion of the door to the air handler closet between resident rooms #6 and #8.
  4. Several dark spots/stains were observed on the carpet of the stairs leading to the basement, and on the carpet in the basement hallway.
Plan of correction
ED, Maintenance, and housekeeping staff will ensure that air handler closet will be free of dirt and dust by cleaning inside of closet monthly. Housekeeping will dust in between horizontal slats weekly to ensure no dirt and dust build up. 05/01/2023 [sic] Spring Oak Management, ED, and Maintenance will Deep clean, and or replace carpet leading to the basement, and downstairs. 07/31/2023 [sic]
22VAC40-73-610-B
Based on a tour of the building and interview with staff, the facility failed to ensure any menu substitutions were recorded on the posted menu.
Evidence
  1. The lunch menu dated 04/26/2023 listed herbed pot roast for the entrée.
  2. The LI observed chipped beef being served as the lunch entrée on 04/26/2023.
  3. Staff # 4 confirmed chipped beef was substituted for the pot roast.
  4. The substitution was not recorded on the posted menu.
Plan of correction
ED, Dietary Manager, and Cook will ensure any menu substitution will be recorded on the posted menu. When an item is substituted on the menu it will be changed on the menu immediately. [sic]
22VAC40-73-380-A
Based on resident record review, the facility failed to document all information required by standards on the resident personal and social data information sheet.
Evidence
  1. Page two of the personal/social data was left blank for strengths and problems under current behavioral and social functioning for resident #1, #2, #3, #, and #8
  2. Page two of the personal/social data was left blank for the following areas: strengths and problems under current behavioral and social functioning; previous mental health or intellectual disability; and substance abuse history for resident #5
Plan of correction
ED and DON will ensure that all standards on the resident personal and social data 2+information sheet are recorded. ED, and DON will audit each resident’s chart to ensure strengths, problems, under current behaviors, and social functioning are filled out. [sic]
22VAC40-73-680-H
Based on a review of medication administration records (MARs) and interviews with staff, the facility failed to document on the MAR all medications administered to residents, including over-the-counter medications and dietary supplements, for four residents.
Evidence
  1. There were no staff initials on the MAR for resident # 9 indicating the following medications were given on 04/08/2023: Atorvastatin Calcium 40mg tablet, 4pm and 8pm doses, and Hydralazine Hydrochloride 25mg tablet, 4pm dose.
  2. There were no staff initials on the MAR for resident # 10 indicating the following medications were given on 04/17/2023: Gabapentin 100mg cap and Lisinopril 40mg tab, 6am doses.
  3. There were no staff initials on the MAR for resident # 11 indicating the following medication was given on 04/02/2023: Humalog 100U/ML Vial/15 units, 4:30pm dose. There were no staff initials on the MAR for the same resident indicating the following medications were given on 04/08/2023: Acetaminophen 500mg Tablet and Lantus 100U/ML Vial, 45 units, 8pm doses, Humalog 100U/ML Vial, 15 units, 4:30pm dose, and Lubricant 0.6% Opth Eye Drops, 5pm dose.
  4. There were no staff initials on the MAR for resident # 13 indicating the following medications were given on 04/08/2023: Diltiazem 30MG tablet, 4pm dose, and Ketorolac 0.5% Opth Sol 5ML, 5pm dose. There were no staff initials on the MAR for the same resident indicating the following medication was given on 04/22/2023: Latanoprost 0.005% Op Sol, 8pm dose.
Plan of correction
ED, DON, and RMA will ensure that the MAR is filled out at the time the medication is given. ED,DON, and RMA will audit the MAR each shift to ensure proper documentation on all medication given. [sic]
April 26, 2023Complaint survey0 violations
Inspection dates
04/26/2023
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 GROUND
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: 04/26/2023 Begin: 9:11am End: 10:00am 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 04/14/023 regarding allegations in the area(s) of: resident care and physical abuse. 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 Crystal B. Henson Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 21, 2023Complaint survey0 violations
Inspection dates
03/21/2023
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: 03/21/2023 Begin: 150pm End: 2:48pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Crystal B. Henson Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 28, 2022Inspection0 violations
Inspection dates
12/28/2022
Comments
Type of inspection: Initial Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/28/2022 Begin: 11:10am End: 12:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The fire and emergency plan will need to be updated to include the new licensee/corporation names prior to the licensure of the new corporation. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Crystal B. Henson Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.