Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 3, 2025
Visit Reason
The inspection was conducted as a complaint investigation to determine compliance with resident care and related services standards.
Findings
The investigation found no evidence to support the allegation of non-compliance with standards or law. No violation notice was issued.
Complaint Details
The complaint was investigated and found to be unsubstantiated based on the evidence gathered during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 3, 2025
Visit Reason
The inspection was conducted as a complaint investigation to determine compliance with standards or laws based on an allegation.
Findings
The investigation found no evidence to support the allegation of non-compliance with standards or law. No violation notice was issued.
Complaint Details
The complaint was investigated and found to be unsubstantiated as the evidence did not support the allegation of non-compliance.
Inspection Report
Renewal
Census: 49
Deficiencies: 0
Dec 4, 2024
Visit Reason
The inspection was conducted as a renewal of the facility's license.
Findings
The inspection found no violations with applicable standards or laws. The licensing inspector completed a tour of the physical plant and reviewed resident and staff records, as well as conducted interviews.
Report Facts
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Deficiencies: 0
Apr 8, 2024
Visit Reason
The inspection was a monitoring visit conducted on April 8, 2024, to review compliance with applicable standards and laws for the assisted living facility Spring Oak Tri-Cities LLC.
Findings
The inspection found no violations with applicable standards or laws. The inspection summary will be posted publicly within five business days.
Inspection Report
Renewal
Census: 34
Deficiencies: 6
Sep 21, 2022
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for continued licensing of the assisted living facility.
Findings
The inspection found non-compliance with several standards related to resident placement approvals, staff orientation and training, tuberculosis risk assessments, annual resident assessments, individualized service plan updates, and annual rights reviews for residents and staff. Violations were documented and a violation notice was issued.
Deficiencies (6)
| Description |
|---|
| Failed to obtain approval prior to placement of a resident in a safe secure environment. |
| Failed to ensure that orientation and training occurred within seven days of employment for staff. |
| Failed to maintain and include an initial tuberculosis risk assessment in staff records. |
| Failed to complete an annual uniform assessment instrument for all residents. |
| Failed to ensure individualized service plans are reviewed and updated every 12 months. |
| Failed to review annually with each resident or staff person the rights and responsibilities of residents in an assisted living facility. |
Report Facts
Number of residents present: 34
Number of resident records reviewed: 7
Number of staff records reviewed: 5
Number of resident interviews conducted: 3
Number of staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Sep 21, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2022-08-11 regarding allegations in the areas of Staffing and Supervision, Resident Care and Related Services, and Resident Accommodations and Related Provisions.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No violation notice was issued.
Complaint Details
Complaint investigation related to allegations in Staffing and Supervision, Resident Care and Related Services, and Resident Accommodations and Related Provisions. The complaint was not substantiated.
Report Facts
Number of residents present: 34
Number of resident records reviewed: 2
Number of staff records reviewed: 5
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 2
Inspection Report
Renewal
Census: 27
Deficiencies: 0
Oct 21, 2021
Visit Reason
A renewal inspection was initiated to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found no violations with applicable standards or law; no deficiencies were issued.
Report Facts
Resident records reviewed: 4
Staff records reviewed: 3
Inspection Report
Monitoring
Deficiencies: 3
Aug 27, 2021
Visit Reason
A non-mandated focused monitoring inspection was initiated to conduct an intensive plan of correction and risk profile follow-up in the areas of Staffing and Supervision, Resident Care and Related Services, and Building and Grounds.
Findings
The inspection found non-compliance with applicable standards, including failure to maintain a current pharmacy reference guide, inability to double lock narcotic medications due to broken locked cart section, and unavailability of certain PRN medications in the medication cart. Plans of correction were initiated to address these issues.
Deficiencies (3)
| Description |
|---|
| Facility failed to maintain a current pharmacy reference book, drug guide or medication handbook available to staff who administer medications. |
| Controlled substances were not kept in a locked container within the locked medication cart due to broken narcotic box. |
| PRN medications Acetaminophen, Loratadine, and Nitroglycerin were not available in the medication cart as listed on the August 2021 MAR. |
Report Facts
Medication cart audit frequency: 5
Medication cart audit frequency: 4
Medication cart audit frequency: 2
Copies of drug reference guide ordered: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tamara Watkins | Inspector | Named as current inspector conducting the inspection |
Inspection Report
Monitoring
Census: 27
Deficiencies: 6
May 25, 2021
Visit Reason
A monitoring inspection was initiated on May 25, 2021, conducted remotely due to a state of emergency health pandemic, including a follow-up on previously cited high risk violations and an intensive plan of correction.
Findings
The inspection found multiple violations including insufficient staffing in the memory care unit with fewer than two direct care staff awake on duty during various shifts, failure to maintain accurate and updated staff work schedules, and multiple medication administration issues such as late doses, failure to document medication administration or omission, and failure to administer medications according to physician instructions.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure at least two direct care staff awake on duty at all times in the special care unit during day shifts. |
| Facility failed to ensure at least two direct care staff awake on duty at all times in the special care unit during night shifts. |
| Facility failed to maintain a written work schedule including names, job classifications, in charge staff, and changes. |
| Facility failed to ensure medications were administered not earlier than one hour before and not later than one hour after the standard dosing schedule. |
| Facility failed to administer medications in accordance with physician's instructions and standards of practice. |
| Facility failed to document medication administration or omission on Medication Administration Records at the time of administration. |
Report Facts
Residents in memory care unit: 10
Current census: 27
Late medication doses Resident #1: 64
Late medication doses Resident #2: 20
Late medication doses Resident #3: 16
Late medication doses Resident #4: 12
Late medication doses Resident #5: 5
Unrecorded medication doses Resident #1: 51
Unrecorded medication doses Resident #2: 7
Unrecorded medication doses Resident #3: 70
Unrecorded medication doses Resident #4: 54
Inspection Report
Complaint Investigation
Deficiencies: 11
Dec 2, 2020
Visit Reason
A complaint inspection was initiated due to allegations in the areas of Personnel; Staffing and Supervision; Resident Care and Related Services; and Building and Grounds. The investigation was conducted remotely due to the state of emergency health pandemic.
Findings
The investigation found multiple violations including failure to implement proper infection control consistent with CDC guidelines, failure to ensure designated staff coverage when the administrator was not on premises, failure to maintain accurate staff schedules, failure to post the person in charge conspicuously, failure to maintain current medication management plans, and multiple medication administration errors including late or missed doses and inadequate documentation.
Complaint Details
The complaint was substantiated. Allegations included issues with Personnel, Staffing and Supervision, Resident Care and Related Services, and Building and Grounds. The investigation confirmed non-compliance with standards and violations were issued.
Deficiencies (11)
| Description |
|---|
| Facility failed to implement infection control program consistent with CDC guidelines; staff observed not properly wearing masks. |
| Facility failed to ensure designated direct care staff member was in charge when administrator was not on premises. |
| Facility failed to maintain a written work schedule including names, job classifications, and designation of person in charge. |
| Facility failed to post the name of the current on-site person in charge in a conspicuous place. |
| Facility failed to provide a method of communication on all shifts to keep direct care staff informed of significant happenings. |
| Facility failed to keep medication management plan current and inclusive of all required components. |
| Facility failed to ensure medications were administered within one hour before or after scheduled times; numerous late administrations documented. |
| Facility failed to administer medications according to physician's orders and standards of practice; missed medication doses documented. |
| Facility failed to document diagnosis, condition, or specific indications for administering drugs or supplements on Medication Administration Records. |
| Facility failed to notify resident's physician and document actions taken in event of medication errors. |
| Facility failed to have a fully functional signaling device that allowed staff to determine the origin of the signal audibly and visibly. |
Report Facts
Prescribed medications administered late: 413
Prescribed medications administered early: 76
Prescribed medications administered late (less than 1 hour): 43
Medication doses missed or not documented: 8
Medication doses missed or not documented: 16
Medication doses missed or not documented: 2
Medication doses missed or not documented: 5
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