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: May 15, 2023 and May 16, 2023

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

1. Discussed coverage when dining services director is on leave to ensure menu on the first floor of assisted living is posted in a timely manner. All other assisted living floors/units had a current menu posted. 2. Reviewed standard 950.E which requires residents, staff and volunteers sign and date the reviews for emergency preparedness and response plan.

Comments:

Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/15/2023 from approximately 8:15 am to 5:30 pm and 5/16/2023 from approximately 8:20 am to 6:15 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 90 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 + selected sections of an additional 8 records Number of staff records reviewed: 5 + selected sections of an additional 6 records Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 6 Observations by licensing inspector: activities, meals, medication administration, medication cart, first aid kit, controlled medication count sheets and corresponding medications, staff schedules, etc. Additional Comments/Discussion: Fire, health and elevator inspections were reviewed as well as previous violations. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-260-C
Description:	Based upon documentation and an interview, the facility failed to ensure the posted list of staff with first aid (FA) and cardiopulmonary resuscitation (CPR) certification was kept up to date. Evidence: 1. On 5/16/2023, the LI (licensing inspector) observed the FA/CPR list taped to the back of the clipboard where the staff schedule was kept and posted. The list included staff 11, 12 and 13 who were no longer employed. 2. On 5/16/2023, the LI interviewed staff 14 who reviewed the list and confirmed staff 11, 12 and 13 were no longer employed.
Plan of Correction:	First Aid/CPR licensures will now be posted on our weekly schedule along with team members name and credentials. This list/schedule will be updated by our AL Coordinator any time there is a new hire or a team member leaves.
Standard #:	22VAC40-73-680-D
Description:	Based upon documentation and an interview, the facility failed to ensure one medication for one of five residents was administered in accordance with the standards of practice outlined in the medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. Resident 7 had a signed physician?s order for Ozempic Solution inject 1mg subcutaneously in the evening every seven days. 2. On 5/15/2023, the LI reviewed the January through May electronic medication administration records (eMARs) for resident 7 and staff 15, a registered medication aide (RMA), initialed the eMAR on 3/21/2023 at 5:00 pm as administering Ozempic subcutaneously. 3. The Virginia Board of Nursing only allows RMAs to administer insulin subcutaneously. 4. According the Virginia Board of Nursing Registered Medication Aide Curriculum, RMAs may not administer non-insulin injections: Page 54 of the curriculum states: ?3. Non-insulin injections a. Medication aides may not administer pursuant to 18VAC90-60-110(B)(5)?
Plan of Correction:	Clinical Coordinators in AL/Memory Support will review all orders that are received and will ensure that any injectable medication falls within the scope of practice for an RMA. Other injectable medications (other than Insulins) will contain directions that they can only be administered by an LPN/RN. Chart reviews will be occurring quarterly.
Standard #:	22VAC40-73-950-E
Description:	Based upon documentation and an interview, the facility failed to ensure semi-annual reviews of the emergency preparedness and response plan (EPRP) with residents were documented by signing and dating. Evidence: 1. The EPRP training conducted on 10/5/2022 and 4/5/2023 for residents 1. 2.3, 4. 5, 6 7, 9 and 10 were not signed and dated by each reisdent. 2. On 5/16/2023, the LI interviewed staff 7 who stated the EPRP reviews were not being signed and dated by the residents as many of them became anxious about signing paperwork.
Plan of Correction:	Emergency Preparedness drills that occur every 6 months will include resident signatures/initials to ensure attendance occurred. Signatures/initials will be obtained and monitored by Director of ALF/Activities Director.