VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: March 23, 2022 and March 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 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:

1. Clarify the individualized service plan versus the plan of care on all hospice agreements. 2. Update the mental health agreement with the correct standards. 3. Do not draw lines through the times on the rounds sheet - each time period must be initialed by the staff who conduct each round. 4. Ensure when you post all menus for the month that the current menu remains on top. 5. Recommended more detail be included in the communication log. 6. Ensure if the source of oxygen is portable tank and concentrator that both are listed on the signed physician's order. 7. Even though the storage cases were labeled, ensure glucometers are also labeled.. 8. Recommended keeping a copy of the training provided with the staff/resident sign in sheet. 9. Discussed providing a copy of the medication administration record versus medication administration list to emergency personnel. 10. Recommended having residents sign on the individualized service plan that they received a copy.

Comments:

An unannounced monitoring inspection was conducted on 3/23/2022 from approximately 8:00 am to 4:40 pm and on 3/24/2022 from approximately 8:00 am to 5:10 pm. Upon arrival there were 26 residents in care and one nurse, one registered medication aide and three direct care aides on duty. A tour was immediately conducted of the interior and exterior of the facility. All of the required postings were in place and the facility was clean and free from any foul odors. The posted menu and the activities calendar accurately reflected this inspector's observations with the menu reflecting the one substitution observed. Meals were observed and the special diets reviewed were served according to the physicians' orders. Medication administration observations were completed with three residents. The medication administration records, physicians' orders and medications were reviewed. Individual interviews were conducted with residents, family members, outside agency staff and facility staff. Six resident, two contract staff and four facility staff records were reviewed. Selected sections of seven additional residents and four staff records were also reviewed. The areas of noncompliance included first aid and cardiopulmonary resuscitation posting, staff work schedule, individualized service plans, medication administration, medication reviews, over-the-counter medications, physicians' orders, storage of cleaning supplies and fire drills. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection.

Violations:

Standard #:	22VAC40-73-260-C
Description:	Based upon observations, documentation and an interview, the facility failed to ensure the posted list of staff with current certifications in first aid (FA) and cardiopulmonary resuscitation (CPR) was kept current. Evidence: 1. During a tour of the facility on 3/23/2022, the list of staff with FA/CPR certifications was observed posted in the staff office. 2. On 3/23/2022, the LI interviewed staff 12 who stated the posted list was not current. 3. When reviewing the posted list of staff with current FA and CPR along with the list of current staff provided by the administrator, staff 9 and 10 were listed; however, they were no longer employed by the facility. 4. Staff 5 was not on the posted list; however, was currently employed with both FA and CPR certifications on file.
Plan of Correction:	The listing of staff who are currently certified in first aid and CPR was updated on 3/24/2022. When a new staff member is hired or a staff member leaves the facility, the wellness director will update the CPR/first aid list. To ensure compliance, the executive director will review the list biweekly for any updates.
Standard #:	22VAC40-73-290-A
Description:	Based upon documentation and interviews, the facility failed to ensure the staff schedule included who was in charge at any given time. Evidence: 1. The staff schedule for March 2022 did not indicate the staff person in charge. At the top of the schedule was the statement, "RMA=M=Charge Person when administrator is out." The schedule, however, had no "M" noted anywhere nor did it indicate anywhere on the schedule who was in charge at any given time. 2. On 3/24/2022, the LI interviewed the nurse and administrator and both stated the staff in charge was not indicated on the staff schedule.
Plan of Correction:	The staff schedule was updated on 3/24/2022. The wellness director will create the schedule and place a "m" by the staff person in charge indicating they are the charge person for that shift. The executive director will review the schedule prior to posting to ensure each shift has one charge person listed for each day and shift. This schedule will be reviewed daily by the wellness director and executive director to update any changes to the charge person. There will be one person listed in charge on the staff schedule in the absence of the administrator.
Standard #:	22VAC40-73-450-F
Description:	Based upon documentation and an interview, the facility failed to ensure four of the six individualized service plans (ISPs) reviewed included all of the assessed needs of the residents. Evidence: 1. The uniform assessment instrument (UAI), signed as completed on 2/28/2022 for resident 2, indicated mechanical help needed for toileting and mobility and that resident 2 was a high risk for falls; however, these needs were not listed on the ISP completed on 2/28/2022. 2. A physician's order, signed 1/10/2022 for resident 3 stated, "Premarin Vaginal Crm-Appl apply 0.5gm vaginally on Monday, Wednesday, and Friday for vaginitis. May keep at bedside and self-administer;" however, the ISP indicated staff were to administer medications. 3.The UAI, signed as completed on 10/10/2021 for resident 5, indicated mechanical help and physical assistance needed for bathing; however, no mechanical help was listed. 4. Resident 5 had an order signed 10/15/2021 for a low/no concentrated sweets diet; however, the ISP completed 10/20/2021 indicated resident was on a regular diet. 5. The ISP, signed as completed on 8/26/2021, was updated on 3/10/2022 to include wound care; however, the care and services provided by outside agency staff, as well as monitoring techniques and services provided by the facility staff, were not listed. 6. On 3/24/2022, the LI interviewed staff 12 who checked the ISPs and stated the above needs were not listed.
Plan of Correction:	The regional director of nursing, in conjunctions with the wellness coordinator, will complete a 100% audit of the UAIs and the ISPs to ensure all areas needing support listed on the UAI are captured on the ISP. A 100% audit will be completed on ISPs by the regional director of nursing and the wellness coordinator to ensure any changes in status are captured on the ISP. The executive director will perform an audit on 25% of residents' ISPs quarterly to verify compliance using a community spreadsheet.
Standard #:	22VAC40-73-650-B
Description:	Based upon documentation, the facility failed to ensure all physicians' orders for one of three residents included a diagnosis for each medication. Evidence: 1. Medication orders for resident 4 were as follows: Miralax and Colace (signed 3/3/2022); Amlodopine, aspirin, Co Q-10, Donepezil, Lisinopril, Lorazepam, Pantoprazole, Rosuvastatin and Vitamin D3 ( all signed 2/28/2022). 2. None of these orders included a diagnosis.
Plan of Correction:	The regional director of nursing contacted the resident's physician to get a diagnosis for each medication listed. A 100% audit was conducted by the executive director, regional director of nursing and wellness coordinator to ensure that all residents' medications have a diagnosis. All future physicians' orders will be reviewed by the wellness coordinator or regional director of nursing to ensure all information is present prior to placing in the resident's record or MAR. The wellness coordinator will conduct weekly audits of all physicians' orders and MAR records to prevent future violations.
Standard #:	22VAC40-73-680-D
Description:	Based upon documentation, the facility failed to ensure one medication for one of seven residents was administered in accordance with the physician's order. Evidence: 1. Resident 5 had a physician's order signed 1/10/2022 for, Novolog Flexpen daily at 7:30 am, 11:30 am and 4:40 pm. Sliding scale150-200 inject two units, 201-250 inject four units, 251-300 inject six units, 301-350 inject eight units, greater than 351 inject 10 units; hold if blood glucose (BG) is less than 150. 2. Resident 5 had a physician's order signed 1/10/2022 for Basaglar Kwikpen inject 30 units subcutaneously every morning, hold if BG is less than 60. 3. Resident 5 had a physician's order signed 1/10/2022 to check blood sugar three times daily at 7:30 am, 11:30 am and 4:30 pm. 4. The medication administration record (MAR) for 2/15/2022 at 5:00 pm for resident 5 indicated staff 11 checked resident's blood sugar and the result was 239. 5. The MAR for 2/15/2022 at 4:30 pm for Novolog sliding scale was blank for the site and BG level and staff 11's initials were circled. The note on the MAR stated, "Withheld per DR/RN orders." 6. On 2/16/2022, the administrator reported staff 11 administered 14 units of Basaglar instead of 14 units of Novolog on 2/15/2022 at 5:00pm. 7. Staff 11 completed a written report on 3/25/2022 which stated "Gave resident wrong insulin."
Plan of Correction:	Staff member 11 was educated on our policy and procedure for medication administration. Staff also completed a medication refresher course provided by the pharmacy on 2/17/2022. All medication aides will be re-educated on medication administration policy by the regional director of nursing. Wellness coordinator or regional director of nursing will complete a medication oversight quarterly for every medication aide.
Standard #:	22VAC40-73-680-G
Description:	Based upon observations and an interview, the facility failed to ensure three of 15 over-the-counter medications reviewed for three residents were labeled with the resident's name. Evidence: 1. On 3/23/2022 the LI, along with the registered medication aide (RMA) on duty, checked the medications administered to resident 4 and three of the medications ( Vitamin D3, aspirin and COQ10) observed were not labeled with the resident's name. 2. Staff 1, the RMA on duty, also checked the medication bottles and during the interview stated the three medications did not have a resident's name on them.
Plan of Correction:	The wellness coordinator will ensure that all medications ordered for all residents are properly labeled with complete instructions for administration and labeled with the resident's name. A cart audit was completed by the regional director of nursing on 4/1/2022 to ensure all medications are properly labeled. When a medication comes in for a resident, the medication aide on duty will check the medication against the order and label it with the resident's name if it is not already done.
Standard #:	22VAC40-73-690-B
Description:	Based upon documentation and an interview, the facility failed to ensure a medication review was conducted at least once every six months. Evidence: 1. Medication reviews were dated as completed by the pharmacy on 4/2020, 10/2020 and 10/2021. 2. On 3/23/2022, the LI interviewed the administrator who stated the medication review was only conducted once during this past year.
Plan of Correction:	Executive director contacted the pharmacist on 4/7/2022 to schedule the review of all resident medications. Ongoing the executive director will be responsible for scheduling with the pharmacy biannual visits by the pharmacist to ensure they are conducted and all medications reviewed. The executive director will ensure this completion by reviewing the dates of scheduled times of the med review with the regional director of nursing at the managers meetings monthly
Standard #:	22VAC40-73-860-I
Description:	Based upon observations and an interview, cleaning supplies were left unlocked and unattended. Evidence: 1. On 3/23/2022 at approximately 9:00 am, the (licensing inspector) LI observed the facility cleaning cart in front of the bulletin board just outside the dining room. Numerous cleaning supplies were left on top of the cart and there were no staff in the area for approximately five minutes. 2. On 3/23/2022, the LI interviewed staff 8 who stated she was not aware that cleaning supplies had to be kept locked at all times when not in use.
Plan of Correction:	On March 23, 2022, identified items were immediately removed and placed under lock. All staff were retrained on all shifts on 4/1/2022 regarding the storage of cleaning supplies in a locked cabinet. Regular rounds by the maintenance director and executive director will be conducted and monitoring will be ongoing to ensure all cleaning supplies are locked when unattended.
Standard #:	22VAC40-73-970-A
Description:	Based upon documentation and an interview, the facility failed to ensure fire drills were conducted on each shift every quarter. Evidence: 1. Fire drill forms completed from 5/20/2021 through 2/14/2022, indicated the only fire drills conducted on the 10:00 pm to 6:00 am shift were completed on 5/20/2021 and 12/27/2021. 2. On 3/23/2022, the LI interviewed the administrator who stated these were the only fire drills conducted on the 10:00 pm to 6:00 am shift.
Plan of Correction:	On 3/24/2022, a fire drill was conducted for the 10:00 pm to 6:00 pm shift. The maintenance director will hand in all fire drills to the executive director prior to filing to ensure that the correct shift has been completed for the month and a fire drill is conducted on each shift every quarter.