VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bridgewater Home, Inc.
302 N. Second Street
Bridgewater, VA 22812
(540) 828-2550

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: April 23, 2020 and April 24, 2020

Complaint Related: No

Areas Reviewed:

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 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

Answered questions and discussed the following: 1) When residents self-administer only a portion of their medications, ensure the specific self-administered medications are listed on the individualized service plan (ISP) and the uniform assessment instrument and not just that the resident self-administers some medications. 2) Continue to document efforts to obtain first aid and cardiopulmonary resuscitation training during the state of emergency. 3) Be specific on resident D's ISP as to the services staff provide to the resident while bathing - do not just state staff assist with bathing. Include what staff specifically do during the bathing process. Ensure specific information is included for all activities of daily living for all residents. 4) Upon receipt, send updated mental health agreement to this inspector.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. An unannounced monitoring inspection was initiated on 4/23/20 and concluded on 4/24/20. The director of assisted living was contacted by telephone to initiate the inspection. The director of assisted living reported that the current census was 70. The inspector emailed the director of assisted living a list of items required to complete the inspection. The inspector reviewed four resident records, four staff records, staff schedules, fire drills, staff annual training, emergency preparedness and resident emergency training, dietary reviews, health care oversight and four residents' medication administration records and physicians' orders submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with first aid training and the violation was documented on the violation notice issued to the facility. Thank you for your cooperation during this inspection.

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based upon documentation and an interview, the facility failed to ensure one of four staff completed first aid training. Evidence: 1) Staff D (hired 5/14/19) had no documentation of first aid training completion. 2) On 4/24/20, the licensing inspector interviewed the director of assisted living who stated the staff was in a nursing program and thought this was acceptable for first aid training. She stated staff D did not have a certificate of completion of first aid training on file.
Plan of Correction:	The registered medication aide (RMA) is enrolled in a HeartSaver class for May 18, 2020, and at that time will be certified in first aid. When on-boarding team members, a new hire checklist will include not only cardiopulmonary resuscitation (CPR) but also first aid certification for all RMAs and certified nursing aides (CNAs). On-boarder will ensure that new hires have mandatory training/certification and checklist will be filed in the Human Resources file.