VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Birch Ridge (Augusta CO)
54 Imperial Drive
Staunton, VA 24401
(540) 885-0065

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Aug. 19, 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 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. 22VAC40-80 THE LICENSING PROCESS.

Technical Assistance:

1) Even though the dietitian completes a summary in each resident record after each review, ensure a list of the names of the residents reviewed are attached to the overall summary of the findings. 2) Recommended having a designated staff to review all paperwork prior to filing to ensure all information is accurate and complete and that sections are not left blank but are noted with "N/A" when appropriate. 3) Keep all of the pages of the physical together - do not separate this document into different sections of the residents' records. 4) Ensure an outline of each in-service training is attached to the training sign-in sheet.

Comments:

An announced initial inspection was conducted on 8/19/19 from approximately 7:40 am to 6:00 pm. A tour was immediately conducted of the facility. The resident rooms that were checked met the requirements. All of the general postings were in place and the facility was clean and free from any foul odors. There were 23 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 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 #:	22VAC40-73-70-A
Description:	Based upon documentation, the facility failed to ensure a major incident was reported to the licensing office. Evidence: 1) On 8/19/19, the licensing inspector (LI) reviewed resident D's record which indicated as of 8/1/19, the resident was admitted with a stage 3 healing wound; however, this information was not reported to the licensing office. 2) On 8/19/19, the LI interviewed the administrator who stated she had not reported the wound.
Plan of Correction:	The administrator will make sure that all major incidents that have negatively affected or that threaten the life, health, safety or welfare of any resident are reported to the licensing office within 24 hours. Any resident that is admitted with any wound will be reported to the licensing office prior to admission with diagnosis, stage, size, treatments, who will provide the treatments and healing status. Any resident that has any wound or the start of a wound will be reported immediately by the staff to the administrator. Staff will log the information in the communication book and in the resident's chart. This process will ensure all staff are notified and that the administrator will notify the licensing office within 24 hours. The administrator will in-service all staff to ensure knowledge and compliance of the notification process.
Standard #:	22VAC40-73-450-F
Description:	Based upon observations, interviews and documentation, the facility failed to ensure five of the six individualized service plans (ISPs) included all of the needs of and services provided to the residents. Evidence: 1) The ISP (completed 7/15/19) for resident A did not include physical therapy; the ISPs completed on 3/22/19 for resident B and 7/15/19 for resident C did not include oxygen, hospital beds and bed rails; the ISP for resident D (completed 8/1/19) did not include a hospital bed; 2) Physicians' orders were on file for the above and, according to observations of residents and interviews with the administrator, the services were not listed on the ISPs.
Plan of Correction:	The administrator will complete the ISP and then have the facility nurse review for errors and both will sign off on the ISP. The administrator will also have the nurse to review all yearly updates and any updates for a change in status on all residents. The administrator and nurse will review the resident chart on the day of admission and make sure all paperwork is done and in place. The administrator will also ensure all reports from the health care oversight are reviewed and implemented, if appropriate.
Standard #:	22VAC40-73-760-A
Description:	Based upon observations and an interview, the facility failed to ensure a current newspaper was available to residents: Evidence: 1) During the facility tour, the LI checked the living room and sitting areas for a newspaper; however, none were observed. 2) On 8/19/19, the LI interviewed the administrator who stated the facility did not have a newspaper for the residents.
Plan of Correction:	The administrator will ensure the facility has a subscription to a local newspaper. Until the subscription can be purchased and obtained, the administrator will stop and buy a paper daily to ensure there is a paper made available to all residents on a daily basis. The newspaper will be kept in the front sitting area of the facility for all to view.
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 various issues; however, there was no documentation on file regarding the steps that were taken to correct the concerns. 2) On 8/19/19, 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 will be made, typed up and a plan of correction 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 then check with residents to make sure copies of the meeting minutes and resolutions to concerns or recommendations were passed out to all residents and also posted for all to see.