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Birch Gardens
12 Royal Drive
Staunton, VA 24401
(540) 886-5007

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Aug. 20, 2019

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
32.1 Reported by persons other than physicians
63.2 General Provisions.
63.2 Protection of adults and reporting.
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.

Technical Assistance:
Recommendations discussed with the administrator and new licensee:
1) Do not draw lines through the sections of the orientation form - each line must be initialed and dated by the trainer.
2) Recommended an audit be conducted of all files to review and ensure all paperwork, including the orientation form, is accurate and complete.
3) Destroy the short check list for barrier crimes that was created by the previous licensee and only use the list of barrier crimes on licensing's website.
3) Need to differentiate clearly in the file the date of hire and the first day of work.
4) Do not separate the physicals - all pages and attachments must be kept together as one document.
5) First aid is due by 8/25/19 for staff D.
6) Do not thin any initial documents from the residents' records.

Comments:
An announced initial inspection was conducted on 8/20/19 from approximately 7:10 am to approximately 6:30 pm. A tour was immediately conducted of the facility. The resident rooms that were checked met the requirements. All of the general posting were in place and the facility was clean and free from any foul odors. There were 31 residents in care. Randomly selected resident and staff records were reviewed. All of the facility's policies and procedures were reviewed and recommendations for changes were made. The current facility is being sold and is expected to open under new ownership on 8/22/19. The administrator and staff will remain the same. Compliance in several areas of the standards could not be determined during the initial inspection and will be reviewed during future inspections. A six-month conditional license based on the compliance found during this initial inspection will be issued by the licensing administrator. NOTE: A copy of the Certificate of Occupancy with the new owner's name listed must be submitted to the licensing office. Immediately upon selling, new criminal record checks and sworn statements must immediately be completed on all staff and new resident agreements must be signed by and disclosure forms issued to all residents. Also, immediately upon change of the contact email address, please forward this information to this inspector. NOTE: A copy of the Certificate of Occupancy must be submitted to the licensing office with the new owner's name listed. Immediately upon selling, new criminal record checks and sworn statements must immediately be completed on all staff and new resident agreements must be signed by and disclosure forms issued to all residents.

Violations:
Standard #: 22VAC40-73-250-D
Description: Based upon documentation and an interview, five of the 14 staff records reviewed did not have a completed tuberculin (TB) skin test or risk assessment on file prior to the first day of work.

Evidence:
1) The following skin tests were not completed as required: Staff C (hired 12/14/18) completed 1/25/19; staff D (hired 6/25/19) completed 6/28/19; staff H (hired 7/8/19) completed 7/12/19; staff K (hired 6/21/19) completed 6/26/19: staff O (hired 1/9/19) completed 1/11/19.
2) On 8/20/19, the licensing inspector (LI) interviewed the administrator who stated the TB skin tests were not completed prior to the first day of work for the staff listed above.

Plan of Correction: The administrator or designee will review all staff charts prior to their start date to ensure a completed tuberculin test has been completed and filed. The administrator or designee will conduct weekly reviews of new staff to ensure compliance with the standards.

Standard #: 22VAC40-73-450-C
Description: Based upon observations, documentation and interviews, the facility failed to ensure all assessed needs and services provided were included on the individualized service plans (ISPs) for seven of the seven ISPs reviewed.

Evidence:

1) The following residents' ISPs did not include all needs and services: wound care, palliative care, hospital bed and mechanical help for mobility for resident A; carbohydrate controlled diet and do not resuscitate order (DNR) for resident B; mechanical soft diet, physical therapy and bed rail on right side for resident C; DNR, hospital bed, bed rails, tab alarm, physical/speech/occupation therapy, hospice, physical assistance with bathing, mechanical assistance with toileting and wander guard for resident D; DNR, supervision with walking, mechanical and physical assistance with stair climbing and mechanical assistance with mobility for resident E; DNR, hospice and the specific services they provide, mechanical soft diet (as of 7/25/19) and the specific mechanical assistance needed with walking for resident F; bed alarm, half rails, wander guard and pureed diet (as of 7/5/19 and ISP had regular diet) for resident G.
2) Observations of residents and staff interviews confirmed the above needs.
3) On 8/20/19, the LI interviewed the administrator who stated these needs were not listed on the residents' ISPs.

Plan of Correction: A designated staff will complete the uniform assessment instrument training and ISP training and will develop the ISPs. The adminstrator will review all ISPs upon completion. The administrator or designee will complete a facility review of all resident ISPs for accuracy and to ensure they are current. The administrator will review all ISPs upon completion and ensure they reflect the current services the residents are receiving. The administrator or designee will review ISPs weekly and update the ISPs to reflect any changes that occur. The administrator or designee will ensure compliance with this standard.

Standard #: 22VAC40-73-830-E
Description: Based upon documentation and an interview, the facility failed to ensure a written response was provided to the resident council prior to the next meeting regarding recommendations that were made by the council for resolution of problems/concerns.

Evidence:
1) Minutes from the council meetings since the last inspection were reviewed and included issues regarding food service; however, there was no documentation on file regarding the steps that were taken to correct the concerns.
2) On 8/20/19, the LI interviewed the activities staff person who stated this information had not been provided in writing to the council.

Plan of Correction: The administrator will work with the activities director after each resident council meeting to address all concerns with the residents. At this time, between the administrator and the activities director, a resolution or correction plan will be made, typed up and put into place. When this plan is made, copies of it and the meeting minutes will be passed out to all residents prior to the next council meeting. The administrator will check with residents to make sure copies of the meeting minutes and resolutions to concerns or recommendations were passed out to all residents and posted for all to see.

Standard #: 22VAC40-90-40-C
Description: Based upon documentation and an interview, the facility failed to ensure two of the 16 staff criminal record checks (CRCs) were reviewed for barrier crimes.

Evidence:
1) The CRCs for staff S and T were reviewed and found to have convictions for barrier crimes.
2) On 8/20/19, the LI interviewed the administrator who rechecked the code and stated the staff did have barrier crimes.

Plan of Correction: The administrator has completed an audit of all facility employee files to ensure no staff background checks contained a barrier crime. The administrator or designee will complete a review of all new employees' background checks prior to hire to ensure the background does not contain a barrier crime. The administrator or designee will ensure compliance with this standard.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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