1 Inspection Summary
Inspection Reports Summary
Covers 11 inspections · Dec 2020 – Mar 2026Visit Reason
This report covers 11 inspections of Spring Oak Tri-Cities LLC from December 2, 2020 to March 24, 2026, including complaint and routine inspections.
Complaint Details
Four inspections were complaint surveys. Investigations did not support allegations of non-compliance in three complaint inspections with no violations cited. One complaint inspection on December 2, 2020 supported allegations and cited 11 violations.
Findings
Across that history VDSS cited 28 violations under 25 distinct standards. 5 of 11 visits ended with violations and 6 with none. 4 inspections were complaint prompted.
Violations (31)
22VAC40-73-480-E: Facility failed to record rehabilitative services in resident records.
22VAC40-73-940-A: Facility failed to ensure annual fire inspection compliance.
22VAC40-73-440-A: Facility failed to complete annual uniform assessment instrument for all residents.
22VAC40-73-1100-A: Facility failed to obtain approval prior to placement in safe secure environment.
22VAC40-73-250-D: Facility failed to maintain initial tuberculosis risk assessment in staff records.
22VAC40-73-550-G: Facility failed to annually review rights and responsibilities with residents and staff.
22VAC40-73-120-A: Facility failed to ensure orientation and training within seven days of employment.
22VAC40-73-450-F: Facility failed to review and update individualized service plans every 12 months.
22VAC40-73-680-M: PRN medications were not available in medication cart.
22VAC40-73-640-D: Facility failed to maintain current pharmacy reference book available to medication staff.
22VAC40-73-660-A-2: Controlled substances not kept in locked container within locked cart.
22VAC40-73-290-A: Facility failed to maintain written work schedule with staff names, classifications, and changes.
22VAC40-73-680-C: Medications administered outside one hour before or after scheduled dosing times.
22VAC40-73-680-D: Facility failed to administer medications per physician's instructions and standards.
22VAC40-73-680-H: Facility failed to document medication administration at time of administration.
22VAC40-73-1130-A: Facility failed to ensure two awake direct care staff on duty in special care unit day shifts.
22VAC40-73-1130-C: Facility failed to ensure two awake direct care staff on duty in special care unit night shifts.
22VAC40-73-290-A: Facility failed to maintain written work schedule with staff names, classifications, and changes.
22VAC40-73-680-C: Medications administered outside one hour before or after scheduled dosing times.
22VAC40-73-680-D: Facility failed to administer medications per physician's instructions and standards.
22VAC40-73-680-H: Facility failed to document medication administration at time of administration.
22VAC40-73-100-A: Facility failed to implement infection control program consistent with CDC guidelines.
22VAC40-73-190-A: Facility failed to designate direct care staff in charge when administrator not on premises.
22VAC40-73-290-A: Facility failed to maintain written work schedule with staff names, classifications, and changes.
22VAC40-73-290-B: Facility failed to post name of current on-site person in charge conspicuously.
22VAC40-73-300-B: Facility failed to provide communication method on all shifts for staff information.
22VAC40-73-640-A: Facility failed to keep medication management plan current and complete.
22VAC40-73-680-C: Medications administered outside one hour before or after scheduled dosing times.
22VAC40-73-680-D: Facility failed to administer medications per physician's instructions and standards.
22VAC40-73-680-I: Facility failed to document diagnosis or indications for drugs on medication records.
22VAC40-73-680-J: Facility failed to notify physician and document actions after medication errors.
Report Facts
Violations cited: 28
Distinct standards: 25
Inspections on page: 11
Inspections with violations: 5
Complaint visits: 4
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