Springtree Healthcare & Rehab Center
SPRINGTREE HEALTHCARE & REHAB CENTER in ROANOKE, VA — inspection on August 20, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
did not have an actual discharge summary from the hospital in the computer, and they had to utilize what they had. PA #2 stated they did not know if they had a full medication list and they were not at the facility when the Resident was admitted and did not know who approved their orders. On 08/20/25 at 11:30 a.m., the DON provided the survey team with a copy of an in-service/education record dated 08/19/25.
The subject of this in-service was admissions/new.
The facility staff also provide the survey team with a copy of their policy titled, Admitting a Patient with an effective date of 01/29/24.
This policy read in part, PROCEDURE.Obtain provider's orders or verify transfer orders with attending physician for the patient's immediate care.No further information regarding this issue was provided to the survey team prior to the exit conference.
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IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Springtree Healthcare & Rehab Center
3433 Springtree Drive Roanoke, VA 24012
SUMMARY STATEMENT OF DEFICIENCIES
was alert and orientated.Resident #4's care plan included the focus area diabetes mellitus and at risk for pain.
Interventions included administer medications as ordered. Resident #4's clinical record included provider orders for Oxycodone HCL oral tablet 5 mg give 1 tablet by mouth every 6 hours for pain.
The clinical record also included an order for Insulin Glargine inject 40 units subcutaneously at bedtime for diabetes.
The order date and start date were both documented as 08/14/25. A review of Resident #4's medication administration records (MARs) for August 2025 revealed that for 08/14/25 at 9:00 p.m. for Resident #4's Glargine Insulin the facility staff documented a 9.
For the medication Oxycodone on 08/14/25 at 6:00 p.m. the facility nursing staff documented a 9.
Per the preprinted code on the MAR a 9=other/see progress notes. Resident #4's clinical record included the following progress notes.08/14/25 at 6:00 p.m. patient is a new admission, awaiting delivery from the pharmacy.
This progress note did not identify what medication was not available. 08/14/25 at 11:18 p.m., Insulin Glargine unable to administer medication at this time as patient is a new admit and medication hasn't arrived from pharmacy at this time, medication unavailable in Omnicell.
Physician Assistant made aware. A review of the facility stat box list revealed this medication would not have been available in the stat box for administration.
The facility staff provided the surveyor with copies of two policies.
Policy #1 was titled, Medication Unavailability.
This policy read in part, A licensed nurse discovering a medication on order that is unavailable will initiate appropriate steps to ensure medical treatment is provided as ordered.If alternate medication is ordered and is not available, the licensed nurse will activate the backup pharmacy process and procedures.
Policy #2 was titled, Admitting a Patient and read in part, PROCEDURE.Provide pharmacy notification, if applicable.Further review of Resident #4's MAR revealed the nursing staff had administered this resident's insulin on 08/15/25 at 9:00 p.m. and Oxycodone at midnight on 08/15/25. On 08/19/25 at 1:15 p.m. the Director of Nursing (DON), Regional Director of Clinical Services (RDCS) #1 and #2 were notified that Resident #4's insulin and Oxycodone were not available for administration on 08/14/25. No further information regarding this issue was provided to the survey team prior to the exit conference.
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