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: Oct. 7, 2019 and Oct. 8, 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 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:

Issues discussed with the administrator: 1) When a violation is issued, all records must be audited and corrected, not just the records cited. 2) The emergency phone numbers on two of the emergency phones were starting to wear off - make sure these are replaced so numbers remain legible. 3) Discussed mail delivery and the need for the administrator or second shift staff to pick it up and distribute in a timely manner. 4) Ensure the name of the staff in charge remains on the dry erase board throughout the day. Recommended considering a more permanent way to post. 5) The summary for the dietary oversight is due on 10/10/19. 6) The medication review is due by the end of October 2019. 7) Do not cover the Violation Notice with the Summary. The Violation Notice must be conspicuous to the public, according to the Code of Virginia. 8) Discussed the need to improve communication among all staff, including management to staff. 9) Staff A, B and C have 60 days to complete direct care training; direct supervision must continue to be at all times until completion. 10) Ensure all old forms are destroyed and only the new forms are available to avoid using non-compliant forms (such as physicals, personal/social data, orientation, resident agreement, etc.). 11) Annual sworn statements are due for all staff. 12) Staff E must have 18 annual training hours completed by 10/20/19.

Comments:

An unannounced non-mandated monitoring inspection was conducted on 10/7/19 from approximately 7:40 am to 5:25 pm and on 10/8/19 from approximately 7:40 am to 1:30 pm. A tour was immediately conducted of the interior and exterior of the facility. The facility was clean and free from any foul odors and the new licensee had taken steps to remove large trees and shrubs in order to clean up the exterior of the facility. Upon arrival there were 21 residents in care and one nurse, one medication aide and two direct care aides on duty. The posted activities calendar and menu accurately reflected this inspector's observations. Medication administration observations were completed for two residents and the medication administration records, physicians' orders and medications were reviewed. Six resident, one discharge, two contract staff and five staff records were reviewed. Selected sections of four additional resident and three staff records were also reviewed. Individual interviews were conducted with residents, family members and staff. The areas of noncompliance included disclosure statement, staff orientation, staff records, tuberculin skin tests/assessments, posting of staff with current first aid and cardiopulmonary resuscitation certifications, initial physicals, fall risk ratings, resident agreements, individualized service plans, medication storage and medication administration. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection.

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based upon documentation, the facility failed to ensure all residents signed a new disclosure form once ownership of the facility changed. Evidence: Residents B, C, D, E, F and G only had a signed acknowledgement for the disclosure statement from the previous owner.
Plan of Correction:	The administrator will have all current and new residents complete and sign the new disclosure statement that has been approved by the department of social services. The administrator will ensure these new disclosures are in residents' files that are kept in the office. The administrator will review monthly for any errors or any signatures that may have been overlooked.
Standard #:	22VAC40-73-120-A
Description:	Based upon documentation and interviews, the facility failed to ensure three of the five new staff hired since the initial inspection were oriented to all required information within seven days of working. Evidence: 1) Staff A (hired 9/30/19) had no documentation of completion of orientation; staff C (hired 9/13/19) had an orientation form on file; however, it was not signed; staff D (hired 9/3/19) had a signed form on file; however, during the interview on 10/8/19, she could not answer questions related to the orientation training - including where the first aid kit was located. 2) On 10/7/19, the licensing inspector (LI) interviewed the administrator who stated the orientation process needed to be improved to ensure all areas were reviewed and a process needed to be developed to ensure staff knew the required information.
Plan of Correction:	The administrator will ensure all new hire employee charts will be completed with all initial training documentation in place.The administrator will not put any new staff on the floor without all training completed and documentation in place. The administrator will review all current employees' charts on a monthly basis to ensure charts are up to date and complete.
Standard #:	22VAC40-73-250-C
Description:	Based upon documentation and an interview, the facility failed to ensure all required information was on file for seven of the eight staff records reviewed. Evidence: 1) Staff A (hired 9/30/19), C (hired 9/13/19) and D (hired 9/9/19) did not have signed sworn disclosures on file; staff B (hired 9/9/19) did not have an emergency contact or signed acknowledgement of receipt of job description on file. 2) On 10/7/19, the LI interviewed the administrator who stated this information had not been completed and signed for these staff. 3) Staff E, F and I continued to be employed by the new owner; however, new criminal record checks and sworn statements were not completed.
Plan of Correction:	The administrator will ensure all employee charts are completed with all required information and on file. The administrator will keep a file on when employee information needs to be updated. The administrator will review charts monthly for accuracy and will ensure all yearly requirements remain up to date and documented.
Standard #:	22VAC40-73-250-D
Description:	Based upon documentation and an interview, the facility failed to ensure tuberculin (TB) skin tests were completed as required for three of five new staff hired since the initial inspection and all staff who were employed previously prior to change of ownership. Evidence: 1) The most current TB skin test/assessment on file for staff F (hired 8/23/12) was completed on 9/26/18; staff I (hired 6/19/17) was completed on 9/17/18, staff J (hired 9/9/19) did not have a skin test/assessment on file. 2) On 10/7/19, the LI interviewed the administrator regarding TB skin tests/assessments and she stated, "All staff were done in 9/18 and have not been done due to non-payment of the previous licensee for TB tests so the staff could not get them done."
Plan of Correction:	The administrator will ensure all new hire and current employees have an up to date and completed skin test/assessment (which includes TB screenings/skin tests with noted results date and the signature of person screening the test). The administrator will not put any new person on the floor until this screening/test has been completed. The administrator will review all current charts on a monthly basis to ensure all current TB skin test/assessments and all other updated paperwork are completed and in the files.
Standard #:	22VAC40-73-260-C
Description:	Based upon observations, documentation and interviews, the facility failed to ensure the posted list of staff with current first aid (FA) and cardiopulmonary resuscitation (CPR) certifications was kept current. Evidence: 1) On 10/7/19, the LI observed the list of staff with current FA and CPR certifications posted on the bulletin board in the medication room. 2) Two staff were listed that were no longer employed and according to interviews with staff, had not been employed for some time. 3) On 10/7/19, the LI interviewed the administrator who also stated the posted list was not current.
Plan of Correction:	The administrator will maintain a tracking spreadsheet to allow for monitoring compliance. The administrator will audit spreadsheet on a monthly basis for completeness. CPR/FA training will be provided to all care staff and dietary staff within the required time frames.
Standard #:	22VAC40-73-320-A
Description:	Based upon documentation and an interview, the facility failed to ensure the initial physical for the only new resident admitted since the initial inspection contained all required information. Evidence: 1) The physical for resident A (admitted 9/30/19) and completed on 9/25/19, did not include the resident's ability to self-administer medications. 2) On 10/7/19, the LI interviewed the administrator who stated she must have used an old form instead of the new model form.
Plan of Correction:	The administrator will ensure that all initial physicals for new residents are completed and all information is provided. The facility nurse will also review for errors prior to admission as well. The administrator has also added new lines and information for the physicians to help complete the paperwork successfully. The administrator, along with the facility nurse, will review all current charts for errors and to ensure all required information is included.
Standard #:	22VAC40-73-325-B
Description:	Based upon documentation and an interview, the facility failed to ensure fall risk ratings were completed after falls for two of the eight residents reviewed. Evidence: 1) Resident J fell on 9/14/19 and resident K fell on 9/27/19. Both fall risk ratings were dated; however, the forms were blank. 2) On 10/8/19, the LI interviewed the administrator who stated the fall risk rating forms had not been completed for these falls.
Plan of Correction:	The administrator will in-service all staff on completion of fall risk ratings with each resident fall. A fall risk rating will be completed for all other residents upon admission, annually and after any falls. The facility nurse will make sure all fall risks are completed and correct. The facility nurse will review all fall risk forms and charts on a monthly basis for completion.
Standard #:	22VAC40-73-390-A
Description:	Based upon documentation, the facility failed to ensure new agreements with the new owner were completed upon the change of ownership for six of six residents' records reviewed. Evidence: Residents B, C, D, E, F and G only had written agreements on file that were completed with the previous owner.
Plan of Correction:	The administrator will have all current and new residents complete and sign the resident agreement that has been approved by the department of social services. The administrator will ensure these new contracts are in residents' files that are kept in the office. The administrator will review monthly for any errors or any signatures that may have been overlooked.
Standard #:	22VAC40-73-450-A
Description:	Based upon documentation, the facility failed to ensure a preliminary plan of care was completed on or within seven days prior to admission for the only new resident since the initial inspection. Evidence: 1) The only individualized service plan (ISP) on file for resident A (admitted 9/30/19) was a preliminary plan of care completed on 10/1/19. The plan of care was not signed by the resident or family member. 2) On 10/7/19, the LI interviewed the administrator who stated this was the only plan of care that was completed.
Plan of Correction:	The administrator will complete the ISPs and then have the facility licensed practical nurse (LPN) review for errors and sign off on the ISPs as well. The administrator will also have the LPN review all new residents' ISPs to make sure they are complete and on file prior to the seven day requirement. The administrator and the LPN will review the resident's chart on the day of admission and make sure all paperwork is done and on file.
Standard #:	22VAC40-73-450-F
Description:	Based upon observations, documentation and interviews, the facility failed to ensure six of six ISPs included all assessed needs and were updated as the residents' needs changed. Evidence: 1) The ISP (completed 10/1/19) for resident A, did not include fall risk, stair climbing, special diet of finger foods, mechanical and physical assistance with toileting (ISP had no assistance required) or that resident prefers to sleep in a recliner (ISP indicated the resident slept on a sofa bed). 2) According to interviews and observations, resident A requires mechanical and physical assistance with toileting and sleeps in a recliner. According to interviews, resident A has slept in a recliner for years prior to coming to the facility and currently sleeps in the recliner. 3) LI observed resident in her recliner and receiving mechanical and physical assistance with toileting. Interviews with resident and staff verified the resident sleeps in a recliner and requires mechanical and physical assistance with toileting and stair climbing. 4) The ISP (completed 8/21/19) for resident B did not include fall risk, mechanical help with mobility and stair climbing, 5) The ISP (completed 4/30/19) for resident C did not include mechanical soft diet, hospital bed with side rails, allergies and reactions, fall risk, stair climbing, uniform assessment instrument (UAI indicated mechanical assistance with toileting; however, the ISP indicated no assistance. 6) The ISP (completed 7/17/19) for resident D did not include fall risk, stair climbing, the UAI assessed needs of mechanical and physical assistance with bathing (ISP had supervision only), physical assistance with wheeling and dressing, mechanical assistance with toileting and physical/occupational therapies from 6/14/19 through 9/10/19. 7) The ISP (completed 8/1/19) for resident E did not include wound care and stair climbing. The ISP also was not signed by the resident or family member. 8) The ISP (completed 7/15/19) for resident G did not include fall risk, allergies and allergic reactions, stair climbing, disorientation to time (according to UAI) but ISP had place.
Plan of Correction:	The administrator will complete the ISP and then have the facility nurse review for all required information and errors. Both the administrator and nurse will sign off on the ISPs. The administrator will also have the nurse review all yearly updates and any updates for a change in status on all residents. The administrator and nurse will review the residents' charts 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 when appropriate.
Standard #:	22VAC40-73-660-A-1
Description:	Based upon observations, the facility failed to ensure all medications and treatment supplies were kept in a locked storage area. Evidence: On 10/7/19 at approximately 7:40 am, the storage room for the treatment cart was left ajar. The LI opened the door and the treatment cart was just inside the door. The LI was able to open each drawer of the storage cart which contained various types of treatments, eye drops, nasal sprays, creams, etc. The cart and storage room were both left unlocked and unattended. The Li waited just a minute at the door until the nurse and medication aide on duty came to the room and locked the door.I
Plan of Correction:	The administrator and the facility nurse will provide an in-service to properly train all staff on keeping medications and treatment medications stored in a locked cart/room. The administrator and nurse will check the storage areas and carts on a daily basis to ensure proper storage is maintained. The administrator and LPN will provide training on a quarterly basis to ensure all staff are properly trained on the requirement for storing all medications/treatments.
Standard #:	22VAC40-73-680-D
Description:	Based upon documentation, observation and an interview, the facility failed to ensure two of two residents' medications were administered according to the physicians' orders. Evidence: 1) On 10/7/19 at approximately 8:27 am, the LI observed staff F administer one puff of Advair to resident B. The signed physician's order on file and the medication administration record (MAR) indicated resident was to receive two puffs. The LI verified with staff F if she gave one puff and she stated yes, she had only administered one puff. The LI also observed staff F administer Miralax at 10:00 am; however, the standard dosing schedule indicated the medication was to be given at 8:00 am. 2) On 10/7/19 at approximately 9:15 am, the LI observed staff F administer one 750mg tablet of Antacid Chews to resident A; however, the physician's order on file and the MAR indicated one 500mg tablet was to be administered. The LI interviewed staff F and she stated this was the medication the resident's family brought in.
Plan of Correction:	The administrator and nurse will provide training to all medication aides on reading the orders properly of all scheduled medications to ensure the five rights of the residents are met. The nurse will check the medication administration records (MARs) at least monthly to ensure all medication orders are consistent with orders on the MARs and physicians' order sheets (POSs). The administrator and the nurse will provide additional training and monitoring on any new orders that come to the facility to ensure all orders and medications are the same.