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: May 16, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS

Technical Assistance:

None.

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/16/2022 from approximately 10:00 am to 3:45 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: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 (selected sections) Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Additional Comments/Discussion: 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 the violation was 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 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 #:	22VAC40-73-680-I
Description:	Based upon documentation and interviews, the facility failed to ensure all required documentation was included on the medication administration records (MARs) for three of three residents' MARs reviewed. Evidence: 1. The MAR for resident 1 was blank on 5/4/2022 at 5:00 pm for Timolol eye drops; 5/4/2022 at 4:00 pm, 5/5/2022 and 5/12/2022 at 1:00 pm for Tramadol. 2. The MAR for resident 2 did not include a diagnosis for Novolog. 3. The MAR for resident 2 did not include the blood glucose levels and amount of insulin administered on 5/1/2022 at 8:00 am, 12:00 pm and 4:30 pm, 5/5/2022 at 4:30 pm, 5/6/2022 and 5/7/2022 at 8:00 am and 12:00 pm, and 5/13/2022 at 4:30 pm; 5/2/2022, 5/4/2022, 5/6/2022 and 5/7/2022 at 4:30 pm, the amount of insulin administered was not documented. 4. The MAR for resident 3 was not initialed on 5/9/2022 and 5/12/2022 at 2:00 pm for Furosemide, Albuterol and Potassium. 5. On 5/16/2022, the licensing inspector (LI) interviewed staff 1 who stated, "The medications were administered and I don't know why my initials don't show up unless I forgot to sign them off." 6. On 5/16/2022, the LI interviewed residents 1 and 3 and both stated they received their medications and have not missed any.
Plan of Correction:	A 100 percent audit of the MARs was completed by the regional director of nursing and the executive director on 5/24/2022. On 5/23/2022 all registered medication aides were retrained by the regional director of nursing on proper MAR documentation. The regional director of nursing and/or wellness coordinator will review the medication aide documentation daily for the next 30 days and 3 times a week thereafter to ensure compliance with all requirements for documentation of medication administration and to ensure all documentation is recorded accurately on the MARs.