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 and Jan. 24, 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 ARTICLE 1 ? SUBJECTIVITY 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 22VAC40-80 THE LICENSING PROCESS

Technical Assistance:

Questions answered and discussions occurred as follows: 1. At least a two-day supply of food and water must be maintained on site at all times, as well as evidence of availability (through a contract, etc.) for an additional two days must be on file. Recommended keeping a four-day supply of food and water on site at all times. 2. Recommended an in-service with all staff regarding the importance of not interrupting the medication aide when medications are being administered. 3. Recommended printing resident?s name next to signature when not legible (training rosters, etc.).

Comments:

Type of inspection: Renewal 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 6:50 am to 1:00 pm and 3:00 pm to 6:50 pm, 1/24/2023 from approximately 7:00 am to 1:00 pm and 3:30 pm to 6:20 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: 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: 6 + selected sections of 3 additional records Number of staff records reviewed: 4 + 2 contract staff Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 + 1 Collateral Observations by licensing inspector: Meals, medication administration, activities, emergency food and water supplies, postings, first aid kit, staffing. Additional Comments/Discussion: A preliminary review of all non-compliance was conducted at the end of each day of the inspection. The administrator was given an opportunity to ask questions and to provide any missing documentation at those times. 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 #:	22VAC40-73-310-M
Description:	Based upon documentation and an interview, the facility failed to ensure three of the three hospice agreements included all required information. Evidence: 1. The three hospice agreements did not include an acknowledgement that the services provided to each resident by hospice must be reflected on the individualized service plan (ISP). 2. On 1/24/2023, the LI interviewed the administrator who stated the hospice agreements were not updated to include this information.
Plan of Correction:	The administrator has completed a full review of all hospice contracts and has met with the corporate legal team to create a new hospice agreement to include all requirements for regulations 310.M on 2/3/2023. This agreement has been sent to all hospice companies for reapproval and signatures. The administrator will ensure compliance with this standard
Standard #:	22VAC40-73-450-F
Description:	Based upon documentation and interviews, the facility failed to ensure four of the five ISPs were updated to include all assessed needs. Evidence: 1. The uniform assessment instrument (UAI), completed 1/20/2023, indicated resident 1 needed mechanical help (MH) with stairclimbing; however, the ISP completed 11/1/2022, did not specify the type of MH needed. 2. Resident 2 had a physician?s order signed 4/22/2022 for a wander guard; the UAI, completed 4/23/2022, indicated MH for stairclimbing; however, these needs were not listed on the ISP completed 4/23/2022. 3. The UAI, completed 10/18/2022 for resident 3, indicated MH was needed for bathing and mobility; however, these needs were not listed on the ISP completed 10/20/2022. 4. The UAI, completed 11/9/2022 for resident 5, indicated MH was needed for dressing; however, no MH was listed on the ISP completed 11/16/2022. 5. The UAI, completed 1/1/2023 for resident 6, indicated MH and physical assistance for walking, wheeling, stairclimbing and mobility; however, the ISP completed 1/1/2023 did not include any assistance with walking and wheeling, or MH for stairs and mobility. 6. On 1/24/2023, the LI interviewed staff 7 who checked the ISPs and UAIs and stated the above needs were not listed on the ISPs.
Plan of Correction:	The administrator or designee will complete a facility review of all resident ISPs for accuracy and to ensure they are current. The administrator and facility wellness coordinator will review upon completions of all ISPs that they reflect the current needs and services the residents are receiving. The Administrator or designee will review ISPs weekly and update the ISP to reflect any changes that occur. The administrator or designee will ensure compliance with this standard.
Standard #:	22VAC40-73-610-C
Description:	Based upon documentation, observations and interviews, the facility failed to ensure the meals met the United States Department of Agriculture?s (USDA) food guidance system. Evidence: 1. On 1/23/2023, the licensing inspector (LI) observed the breakfast, lunch and dinner meals. A glass of orange juice for breakfast was the only fruit observed being provided to the residents for the three meals. 2. The posted menu for the week of 1/22/2023 to 1/28/2023 listed fruit being served for lunch on 1/23/2023 and dinner on 1/24/2023 and 1/27/2023. The menu listed only two servings of vegetables on 1/23/2023, 1/26/2023, 1/27/2023 and 1/28/2023. There were no noted substitutions on the posted menu. 3. On 1/23/2023, the LI interviewed the cook who stated fruit is only served three times a week. 4. The USDA food guidance system recommends two servings of fruit and three servings of vegetables a day.
Plan of Correction:	Dietary manager was in-serviced on 2/1/2023 regarding nutritional requirement for all menus to meet the USDA food guidance system. The dietary manager will follow the approved dietician menus for all meals to ensure the proper servings of fruits and vegetables are served each day to the residents. The administrator or designee will review the menu each week prior to posting to ensure compliance with this standard.
Standard #:	22VAC40-73-620-A
Description:	Based upon documentation and an interview, the facility failed to ensure the dietary oversight was completed every six months. Evidence: 1. The last dietary oversight on file was documented as completed 6/23/2022. 2. On 1/23/2023, the LI interviewed the administrator who stated the previous dietitian cancelled the contract in August of 2022 and no dietary oversights had been completed since 6/23/2022. 3. On 1/23/2023, the LI interviewed the licensee, collateral 2, who stated he was unaware that the facility did not have a contract with a dietitian and that the dietary oversight had not been completed.
Plan of Correction:	A dietitian was contracted and completed a bi-annual review of resident diets on 2/9/2023 and contracted for services every 6 months and as needed. The administrator will ensure a visit and that documentation of the dietician?s visit is on file every 6 months. The administrator will ensure compliance with this standard.
Standard #:	22VAC40-73-680-E
Description:	Based upon observations, documentation and an interview, the facility failed to ensure a treatment was provided for one of two resident records reviewed. Evidence: 1. Resident 4 had a physician?s order signed 5/18/2022 for Ketoconazole shampoo to be applied to scalp every other day for hair loss. 2. On 1/23/2023, the LI conducted a medication cart audit with staff and the Ketoconazole shampoo was not observed in the medication or treatment cart. Staff 2 stated the shampoo was probably in the resident?s room. 3. On 1/23/2023, the LI interviewed resident 4 who stated she did not have the Ketoconazole shampoo and that it had been about six months since she had it as she got a different shampoo that she liked and used. 4. The January medication administration record (MAR) for resident 4 listed Ketoconazole shampoo every other day and was signed off as being administered on 1/2/2023, 1/4/2023, 1/6/2023, 1/8/2023, 1/10/2023, 1/12/2023, 1/14/2023, 1/16/2023, 1/18/2023, 1/20/2023, 1/22/2023.
Plan of Correction:	All registered medication aides will be in-serviced on medication administration/treatments and that in-service will include proper documentation to ensure physicians? orders are being followed as prescribed and recorded on the MAR/treatment administration record (TAR) accurately. The wellness coordinator or designee will review the MAR/TAR 3 times per week to ensure accuracy of documentation and each medication aide will be observed during a medication pass to ensure all treatments are completed according to the physicians? orders.
Standard #:	22VAC40-73-680-I
Description:	Based upon documentation and an interview, the facility failed to ensure that all medications administered were documented for one of two residents. Evidence: 1. The January MAR for resident 4 was blank on 1/9/2023 for the 10:00 pm doses of Clonazepam, Diphenoxylate-Atropine, Eliquis, Gabapentin, Melatonin and Trazadone. 2. On 1/23/2023, the LI interviewed resident 4 who stated she has never missed her 10:00 pm medications.
Plan of Correction:	All Registered Medication Aides will be in-serviced on the importance of accurate documentation on the MAR. Each Medication Aide will have one medication pass observed by the wellness coordinator with suggestions made to enhance and ensure compliance with accurate documentation of each medication administered. The Wellness Director or Designee will conduct audits 3 times per week of the MAR to check for accuracy in documentation
Standard #:	22VAC40-73-700-1
Description:	Based upon observations, documentation and an interview, the facility failed to ensure signed completed orders for oxygen were on file for two of three residents and that ?No Smoking ? Oxygen in Use? signs were posted at three of the three resident rooms where Oxygen was in use. Evidence: 1. On 1/23/2023, the LI conducted a tour of the facility and observed no oxygen sign posted at any resident door. 2. On 1/23/2023, the LI interviewed the administrator who stated there were three residents on oxygen and provided a list of their names, which included residents 2, 7 and 8. 3. The signed oxygen orders for resident 2 did not include the route or the source. 4. There was no oxygen order on file for resident 7.
Plan of Correction:	?Oxygen in use - no smoking? signs were posted immediately during survey on each resident?s room door with oxygen. Oxygen Orders were obtained with all required documentation by the wellness Coordinator. Wellness Coordinator to in-service all staff and instruct them to place oxygen signs at the entrance to residents? rooms when oxygen is in use. Wellness Coordinator to review all orders for oxygen to ensure they have all required components for any new oxygen orders. The administrator or wellness coordinator will ensure compliance with this standard.
Standard #:	22VAC40-73-970-E
Description:	Based upon documentation and an interview, the facility failed to ensure fire drills were documented as required. Evidence: 1. The fire drill form for the drill held on 6/29/2022 at 10:25 did not indicate am or pm. 2. The fire drill form for the drills held on 10/21/2022 and 1/11/2023 did not include the evacuation time. 3. The fire drill form for the drill held on 1/11/2023 did not indicate the weather. 4. On 1/23/2023, the LI interviewed the administrator who checked the forms and stated they did not include the required information.
Plan of Correction:	A 100 percent audit was completed for all fire drills. The Maintenance Director will conduct a fire drill on each shift quarterly rotating the shifts each month. After completion of the fire drill the maintenance director will then give the monthly fire drill form to the administrator prior to filing to ensure that all required documentation has been completed on the form. The administrator will ensure compliance with this standard.