Inspection Report
Complaint Investigation
Deficiencies: 0
May 8, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-03-06 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted at the facility.
Complaint Details
Complaint investigation related to allegations in resident care and related services; the complaint was not substantiated.
Report Facts
Resident records reviewed: 1
Staff interviews conducted: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 14, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-11-27 regarding allegations related to staff/resident care/contact.
Findings
The evidence gathered during the investigation did not support the allegations or self-report of non-compliance with standards or law.
Complaint Details
Complaint received on 2024-11-27 regarding staff/resident care/contact; investigation did not substantiate non-compliance.
Report Facts
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
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 14, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 09/19/2024 regarding allegations in the areas of resident care and accommodation.
Findings
The investigation did not support the allegations of non-compliance related to the complaint; however, a violation unrelated to the complaint was identified involving failure to complete a fall risk rating for one resident after a fall.
Complaint Details
Complaint related: Yes. The complaint was regarding resident care and accommodation. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (1)
| Description |
|---|
| Facility failed to complete a fall risk rating for one resident after one fall. |
Report Facts
Resident falls documented: 4
Resident records reviewed: 1
Staff interviews conducted: 2
Inspection Report
Renewal
Census: 41
Deficiencies: 3
Jul 9, 2024
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with medication management, availability of PRN medications, and incomplete physician orders for restraints. Violations were documented and a plan of correction was requested.
Deficiencies (3)
| Description |
|---|
| Facility failed to implement their own plan for medication management, resulting in missed doses of prescribed medication. |
| Facility failed to have all medications ordered for PRN administration available for the specific resident. |
| 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. |
Report Facts
Number of residents present: 41
Number of resident records reviewed: 7
Number of staff records reviewed: 3
Number of new employees: 8
Number of interviews with residents: 2
Number of interviews with staff: 4
Missed doses of Pregabalin 200mg: 10
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 12, 2024
Visit Reason
The inspection was conducted as a complaint-related investigation to determine compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection findings determined non-compliance with applicable standards or laws, resulting in documented violations. The licensee was given the opportunity to submit a plan of correction to address the cited violations and maintain future compliance.
Complaint Details
The inspection was complaint-related as explicitly stated. No substantiation status was provided.
Report Facts
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
Inspection Report
Monitoring
Deficiencies: 0
Apr 4, 2024
Visit Reason
The inspection was a monitoring visit conducted on April 4, 2024, to assess compliance with applicable standards and laws.
Findings
The inspection found no violations of applicable standards or laws during the monitoring visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Crystal Henson | Licensing Inspector | Named as the current inspector conducting the monitoring inspection. |
Inspection Report
Monitoring
Deficiencies: 0
Apr 4, 2024
Visit Reason
The inspection was a monitoring visit conducted on April 4, 2024, to assess compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws during the monitoring visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 21, 2023
Visit Reason
The inspection visit was conducted as a complaint-related investigation to determine compliance with applicable standards and laws.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
The inspection was complaint-related, and the evidence did not substantiate the allegations of non-compliance.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Crystal Henson | Licensing Inspector | Named as the current inspector conducting the complaint-related inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 24, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on allegations of non-compliance with standards or law.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
The inspection was complaint-related, but the allegations were not substantiated according to the findings.
Report Facts
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 3
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Crystal Henson | Licensing Inspector | Conducted the complaint-related inspection |
Inspection Report
Monitoring
Census: 58
Deficiencies: 0
Aug 10, 2023
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to assess compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector completed a tour of the physical plant and reviewed resident and staff records without identifying any deficiencies.
Report Facts
Number of resident records reviewed: 3
Number of staff records reviewed: 3
Number of interviews conducted with staff: 2
Number of interviews conducted with residents: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Crystal Henson | Licensing Inspector | Inspector conducting the monitoring visit |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 10, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on allegations regarding medication administration practices at the facility.
Findings
The investigation found that the facility failed to keep medications in their pharmacy-issued containers with prescription labels until administered. Pre-poured medications were observed in clear cups, violating medication administration standards. Staff involved were disciplined, including termination of one staff member.
Complaint Details
The complaint received on 2023-07-14 alleged improper medication administration practices by staff #1, including pre-pouring medications. The investigation substantiated these allegations, leading to staff #1's termination and reporting to the nursing board.
Deficiencies (1)
| Description |
|---|
| Failure to keep medications in pharmacy-issued containers with prescription labels until administration. |
Report Facts
Resident records reviewed: 17
Staff interviews conducted: 2
Date of complaint: Jul 14, 2023
Date of medication incident: May 13, 2023
Date of medication incident: Jul 13, 2023
Residents involved: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Named in medication administration violation and subsequent termination | |
| Staff #2 | Witnessed pre-poured medications and administered medications after staff #1 was removed | |
| Staff #3 | Administered evening medications not documented on July 13, 2023 MAR | |
| Crystal Henson | Licensing Inspector | Conducted the inspection and investigation |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Jul 11, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-06-26 regarding allegations related to resident/staff interaction and medication administration.
Findings
The investigation supported some but not all of the allegations. A violation was found related to failure to administer medications consistent with the standards of practice outlined by the Virginia Board of Nursing.
Complaint Details
The complaint was substantiated in part; evidence supported some allegations related to medication administration but not all.
Deficiencies (1)
| Description |
|---|
| 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. |
Report Facts
Number of residents present: 55
Number of resident records reviewed: 1
Number of staff interviews conducted: 3
Number of resident interviews conducted: 1
Inspection Report
Renewal
Deficiencies: 18
Jul 11, 2023
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including failure to adhere to infection control policies, lack of written documentation for staff duties, improper medication labeling and administration, failure to maintain building safety and cleanliness, and incomplete documentation related to restraints and staff background checks.
Deficiencies (18)
| Description |
|---|
| Facility failed to adhere to infection control policy; resident glucometers not labeled properly. |
| Facility failed to provide written documentation of duties and responsibilities to two staff members prior to being placed in charge. |
| Facility failed to have a written agreement with residents performing staff duties. |
| Facility failed to deny admission to an individual with a prohibitive condition without an appropriate treatment plan. |
| Facility failed to have a qualified health care professional (minimum RN) complete required oversight for restrained residents. |
| Facility failed to follow the posted written schedule of activities. |
| Facility failed to ensure each medication was properly labeled from the pharmacy with directions. |
| Facility failed to administer medications according to standards; non-insulin injection administered by registered medication aide. |
| Facility failed to have over-the-counter medications labeled with resident's name or in pharmacy-issued containers. |
| Facility failed to have all required information documented on the Medication Administration Record (MAR). |
| Facility failed to have medications ordered for PRN administration available, properly labeled, and stored. |
| Facility failed to have physician's order when restraints are used. |
| Facility failed to document usage, outcome, and checks on residents when restraints are in use. |
| Facility failed to maintain hot water taps within required temperature range (105-120°F). |
| Facility failed to keep cleaning supplies and hazardous materials in a locked area. |
| Facility failed to maintain interior and exterior of buildings in good repair and free of rubbish. |
| Facility failed to have nonslip surfaces on ramps, stairways, and steps inside and outside the building. |
| Facility failed to obtain criminal history record reports on or prior to the 30th day of employment for three employees. |
Report Facts
Employment start dates: 3
Inspection duration: 6.33
Water temperature readings: 71.4
Water temperature readings: 75.3
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 26, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-04-14 regarding allegations of resident care and physical abuse.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection summary will be posted publicly within five business days.
Complaint Details
Complaint related to allegations of resident care and physical abuse; the allegations were not substantiated by the investigation.
Inspection Report
Monitoring
Deficiencies: 4
Apr 26, 2023
Visit Reason
The inspection was a monitoring visit conducted to assess compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found multiple violations including incomplete documentation on resident personal and social data sheets, failure to record menu substitutions, incomplete medication administration records, and poor maintenance and cleanliness of the facility.
Deficiencies (4)
| Description |
|---|
| Facility failed to document all required information on resident personal and social data information sheets. |
| Facility failed to ensure any menu substitutions were recorded on the posted menu. |
| Facility failed to document on the medication administration records all medications administered to residents, including over-the-counter medications and dietary supplements, for four residents. |
| Facility failed to ensure the interior and exterior of all buildings were maintained in good repair and kept clean and free of rubbish. |
Report Facts
Residents with incomplete personal/social data: 5
Residents with undocumented medications: 4
Inspection duration hours: 5.4
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 0
Apr 26, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 04/20/2023 regarding allegations in the area of physical plant.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint related inspection with allegations concerning the physical plant; the complaint was not substantiated.
Report Facts
Number of resident interviews: 5
Number of staff interviews: 2
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 21, 2023
Visit Reason
The inspection was conducted as a complaint investigation to determine compliance with standards or laws based on allegations or self-reports.
Findings
The evidence gathered during the investigation did not support the allegations or self-reports of non-compliance with standards or law.
Complaint Details
The inspection was complaint-related, but the allegations were not substantiated as the evidence did not support non-compliance.
Inspection Report
Original Licensing
Deficiencies: 1
Dec 28, 2022
Visit Reason
Initial licensing inspection of the assisted living facility Spring Oak Christiansburg was conducted to evaluate compliance prior to licensure of the new corporation.
Findings
The inspection found that the fire and emergency plan needs to be updated to include the new licensee/corporation names prior to licensure. The Acknowledgement of Inspection form was signed and left at the facility.
Deficiencies (1)
| Description |
|---|
| Fire and emergency plan needs updating to include new licensee/corporation names prior to licensure. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Crystal B. Henson | Licensing Inspector | Inspector conducting the initial licensing inspection. |
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