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: Feb. 23, 2022 and Feb. 24, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 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 General Provisions. 63.2 Licensure and Registration Procedures 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 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS.

Technical Assistance:

1. Recommended creating a checklist for standard 620.B. 2. Include specific dates health care oversights are completed - not just the month and year. 3. Submit March 2022 fire inspection to inspector as soon as it is received.

Comments:

An unannounced renewal inspection was conducted on 2/23/2022 from approximately 8:00 am to 4:15 pm and 2/24/2022 from approximately 8:15 am to 5:00 pm. Upon arrival there were 77 residents in care and nine direct care staff on duty. A tour was immediately conducted of the facility. All required postings were in place and the facility was clean and free from any foul odors. The posted activities calendar and menu accurately reflected this inspector's observations. Interviews were conducted with residents, family members and staff. Ten resident (including one discharge), one volunteer and six staff records were reviewed. Selected sections of two additional resident and staff records were also reviewed. February medication administration records, signed physicians' orders and actual medications were reviewed for five residents. The area of noncompliance included training hours in cognitive impairments. Thank you for your assistance and cooperation during this inspection.

Violations:

Standard #:	22VAC40-73-1140-B
Description:	Based upon documentation and an interview, the facility failed to ensure one of eight staff records reviewed had documentation of completing the required number of training hours in cognitive impairments. Evidence: 1. The training record for staff 5 (hired 10/12/2021) had a total of three hours of training completed in cognitive impairments. 2. According to the staff schedules, staff 5 was assigned to work the secured unit. 3. On 2/24/2022, the licensing inspector (LI) interviewed the director of assisted living (DAL) and she stated staff 5 was assigned to the secured unit. 4. On 2/24/2022, the LI interviewed the DAL and the coordinator of resident services (CRS) and both stated staff 5 had only completed three hours of cognitive impairment training since he was hired.
Plan of Correction:	1. The remaining seven hours of required new hire dementia training for staff 5 will be completed by 3/4/22. All needed training hours will be tracked and recorded by the assisted living coordinator (ALC). 2. All new hires will be required to complete mandatory dementia training by the end of their first month of employment. Educational training through ReLias will be part of the new hire orientation and will be demonstrated by the ALC. 3. The ALC will track all new hire dementia training weekly and will ensure completion by the end of the first month of employment. After week three, team members who have not completed the required training will be verbally contacted by the ALC/DAL and given a verbal warning. If required training hours remain incomplete by the end of the first month, the team member will be removed from the schedule until training has been completed.