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: Jan. 23, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND

Technical Assistance:

When a staff member resigns, the responsibilities must be delegated to other staff and the administrator and licensee must ensure the job duties continue to be completed.

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/23/2023 from approximately 1:00 pm to 3:00 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1/3/2023 regarding allegations in the areas of: Resident Care and Related Services and Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 32 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 (only selected sections) Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 + 2 family members Number of interviews conducted with staff: 4 + 1 outside agency staff Observations by licensing inspector: Resident rooms, common areas, dining room, laundry room, activities room, etc. Additional Comments/Discussion: Preliminary findings were reviewed and discussed with the administrator at the end of the inspection. The administrator was given the opportunity to ask questions and present any documentation or other information related to the complaint during that time. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Activities and housekeeping A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-450-H
Complaint related:	Yes
Description:	Based upon interviews, the facility failed to ensure resident rooms were deep cleaned every week as stated on the individualized service plans (ISPs) for three of the three resident records reviewed. Evidence: 1. On 1/23/2023, the LI conducted a tour of the facility and resident room. In resident 1?s room there were disposable cups, torn pieces of paper and other miscellaneous trash under the bed. 2. On 1/23/2023, the LI interviewed resident 1 who stated her daughter comes and cleans her bathroom. 3. On 1/23/2023, the LI interviewed resident 2 who stated it had been a while since her room had been cleaned. 4. On 1/23/2023, the LI interviewed resident 3 and checked his bathroom where there was feces on the toilet seat. 5. On 1/23/2023, the LI checked resident 4?s room and there were little pieces of paper on the floor. 6. On 1/23/2023, the LI checked resident 5?s room and there were pieces of paper and tissues all over the floor. 7. On 1/23/2023, the LI interviewed the administrator who stated the resident rooms were not receiving a deep cleaning every week as the housekeeper had resigned. 8. On 1/23/2023, the LI interviewed a family member who stated the rooms were not being cleaned and that family members were coming in to clean the rooms and bathrooms. 9. The individualized service plans for residents 1 (completed 10/20/2022, 2 (completed 3/9/2022) and 3 (completed 3/7/2022) listed housekeeping as. ?Staff will clean room and bathroom as needed with a deep clean weekly.?
Plan of Correction:	All resident rooms were deep cleaned by the housekeeper. The maintenance director will complete checks of all rooms weekly to ensure deep clean was completed for each resident weekly. Once every week the administrator will pick 5 rooms at random to ensure all resident rooms were deep cleaned as per ISP. The maintenance director and administrator will be responsible for compliance with this standard.
Standard #:	22VAC40-73-520-E
Complaint related:	No
Description:	Based upon interviews, the facility failed to ensure at least one hour of activities was being held daily with a total of 14 hours each week. Evidence: 1. On 1/23/2023, the LI interviewed the administrator who stated activities were being held two to three times a week in the morning and afternoon. 2. On 1/23/2023, the LI interviewed staff 2 who stated activities were being held about every three or four days. 3. On 1/23/2023, the LI interviewed staff 4 who stated since the activities staff left, he has been helping with activities and they are offered about three times a week.
Plan of Correction:	A new activities director was hired on 2/5/2023 who was given instruction that at least one hour of activities be completed each day with a total of 14 hours per week. Direct care staff will assist with the daily activities in the event the activities director is unavailable. The administrator will review the schedule weekly to ensure that a minimum one hour of activities will be scheduled for each day and 14 hours per week. The administrator will ensure compliance with this standard.