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: May 9, 2022 and May 10, 2022

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

Standards/Information reviewed with the administrator in training: 1. Recommended cart and medication audits be conducted on a weekly basis to ensure medications and treatments are on site and being administered as ordered and that documentation is accurate and complete - this includes the controlled medication count. 2. Recommended nurse conduct medication administration observations at least twice a month to ensure proper protocols are being followed. 3. Reviewed standard 650 which requires each medication order to have a specific diagnosis, condition or specific indications for administering (especially if an as needed/PRN medication), name of the drug, specific dose, strength, route and how often it is to be given. Stating for anxiety is not sufficient. Also, when a cream is ordered the order must indicate where that cream is to be administered and what it is to be administered for. Ensure orders are specific prior to filing and ensure all information is included on the medication administration record. 4. Recommended a more frequent system of checks be implemented with the medication administration records, physicians' orders, resident and staff records, food consumption logs, fire drills and training. 5. Notify inspector once the new walkie-talkies are received. 6. New administrator in training must complete the medication aide class. Send this certificate immediately upon completion.

Comments:

Type of inspection: Monitoring Dates of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/9/2022 from approximately 8:15 am to 5:35 pm and 5/10/2022 from approximately 7:54 am to 4:50 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: 24 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 and selected sections of three additional resident records Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Medication administration observations were completed with one registered medication aide for two residents for a total of 17 medication administration observations. The April and May medication administration records, physicians' orders and medications were all reviewed. All required postings were observed and the medication cart was checked. 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 violations 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 violations 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 #:	22VAC40-73-290-A
Description:	Based upon documentation and an interview, the facility failed to ensure a work schedule was maintained that included all substitutions and changes. Evidence: 1. The staff schedule for April 2022 did not indicate substitutions for the 6:00 am to 2:00 pm shift on 4/1, 4/4, 4/5, 4/12, 4/20; for the 10:00 pm to 6:00 am shift on 4/23, 4/24 and 4/28. 2. The May 2022 schedule did not indicate substitutions for the 6:00 am to 2:00 pm shift on 5/2 through 5/5; 10:00 pm to 6:00 am shift on 5/1 and 5/2. 3. On 5/9/2022, the licensing inspector (LI) interviewed the administrator who stated the changes were not added to the staff schedule.
Plan of Correction:	1. Acting Administrator (AA) and Regional Director of Nursing (RDON) reviewed 22VAC40-73-290 to review all elements of compliance. April and May staffing calendar was reviewed by both AA and RDON and updated to indicate substitutions for the dates and shifts indicated on the violation notice. 2. Beginning 05/13/2022, RDON will report weekly to AA all schedule changes and substitutions for the previous week and AA will update and maintain an accurate and complete schedule to be kept in the compliance binder. 3. RDON and AA are responsible for the implementation and monitoring of this corrective action. 4. This corrective action will be fully implemented by May 16, 2022.
Standard #:	22VAC40-73-410-A
Description:	Based upon record reviews and an interview, the facility failed to ensure four of the six resident records reviewed had signed documentation by the resident that resident orientation was completed. Evidence: 1. Residents 1, 5 and 6 had no documentation of orientation completion and the resident orientation form was not on file. 2. Resident 2 had resident orientation form on file and completed; however, the family member instead of the resident had signed the form. 3. On 5/9/2022, the LI interviewed the administrator who stated the resident orientation forms were not in the residents' records and the family member instead of the resident had signed the form for resident 2.
Plan of Correction:	1. AA and RDON met on 05/13/2022 and discussed the possibility that the missing resident orientations may have been thinned last month and placed in storage. AA to pull the thinned charts to see if this is the case. If not, RDON will meet with residents to review the resident orientation form and collect signature. AA met with resident 2 to review her orientation and obtain signature on 05/09/2022. All active resident charts will be reviewed for compliance. 2. Upon admission, the AA, RDON or charge person will review the orientation form and obtain signature from the resident. The RDON will review the orientation form for accuracy and file in the resident folder. AA is creating a quality assurance form to routinely review records for accuracy and this element will be added to the form. 3. The RDON will be responsible for the monitoring of this preventative measure and will report any areas of ongoing noncompliance to the AA. 4. This corrective action will be fully implemented by June 10, 2022
Standard #:	22VAC40-73-450-F
Description:	Based upon documentation and an interview, the facility failed to ensure four of the six individualized service plans (ISPs) reviewed included all needs and services provided. Evidence: The updated ISPs for the following residents did not include all assessed needs and services provided: 1. On 5/10/2022, the LI interviewed the administrator and nurse and both stated resident 3 required two person assistance; however, the ISP (updated 3/15/2022) for resident 3 did not include the need for two-person assistance. Resident 3 was also receiving wound care by hospice; however, this need was also not listed on the ISP. 2. The uniform assessment instrument (UAI) completed 3/15/2022 for resident 4 indicated resident needed assistance with medication administration; however, the ISP (updated 3/15/2022) did not include this need. The resident also had a physician's order (signed 4/22/2022) to self-administer a gel nasal spray which also was not listed on the ISP. 3. Resident 5 had a physician's order (signed 4/4/2022) for half rail on one side of bed to assist with transferring and positioning. The UAI (completed 3/22/2022) for resident 5 indicated resident needed mechanical assistance with transferring; however, the ISP (updated 3/22/2022) for resident 5 did not include the half rail for assistance with transferring and positioning and also did not include disorientation to time. 4. Resident 6 had a physician's order (signed 4/14/2022) for half rails to assist with transferring and positioning. The UAI (completed 3/15/2022) indicated resident 6 needed mechanical assistance with bathing, transferring, walking, wheeling and mobility; however, the ISP (completed 3/15/2022) did not include these needs.
Plan of Correction:	1. RDON will review and make all necessary corrections to the ISP for residents 3, 4, 5 and 6. RDON will review the UAIs and ISPs for all active residents to ensure accuracy of the service plan and update as needed. 2. AA and Wellness Coordinator (WC) will complete ISP training providing the community with 3 employees trained in this area. Staff meeting scheduled for 05/19/2022 will include an agenda topic to remind all staff of the importance to report any resident change in condition immediately to their supervisor so that the UAI/ISP can be updated in a timely manner. 3. The RDON will be responsible for the monitoring of this preventative measure and will report any areas of ongoing noncompliance to the AA. 4. This corrective action will be fully implemented by June 30, 2022.
Standard #:	22VAC40-73-640-D
Description:	Based upon observation and interviews, the facility failed to ensure at least one pharmacy reference book, drug guide or medication handbook for nurses was readily accessible. Evidence: On 5/10/2022, the LI conducted a medication cart audit and requested staff 2 show her the drug reference book. Staff 2 stated the book was supposed to be in the medication cart; however, upon checking the cart there was no book found. Staff 2 and the administrator also checked the record/medication room and neither could find a drug reference book.
Plan of Correction:	1. AA contacted pharmacy on 05/09/2022 and two drug reference books were delivered that evening. One will be kept in the medication cart and the other is in the AA's office. Staff meeting scheduled for 05/19/2022 will include an agenda topic to remind RMA?s that this is a required element in the medication cart and RDON should be notified immediately if it is found to be missing. 2. WC and RDON will include this element as part of their scheduled audits of the medication cart. 3. WC and RDON are responsible for the implementation and monitoring of this corrective action and will report any areas of ongoing noncompliance to the AA. 4. This corrective action will be fully implemented by May 19, 2022.
Standard #:	22VAC40-73-650-B
Description:	Based upon documentation and an interview, the facility failed to ensure one of two residents' physicians' orders reviewed included a diagnosis for each medication. Evidence: 1. The physician's orders (signed 4/15/2022) for resident 2 did not include a diagnosis for twelve of thirteen medications. 2. On 5/9/2022, the LI interviewed the nurse on duty who stated the physician had not indicated a diagnosis on the orders and the facility had not requested the diagnoses for the medications.
Plan of Correction:	1. RDON contacted physician on 05/10/2022 to obtain diagnosis for the 12 medications identified for resident 2. RDON will conduct a review of the physician orders for all active residents to ensure compliance with this standard. 2. AA will review the physician orders for all new admissions to ensure compliance with this standard prior to admission. RDON will provide a second review upon admission to the community. 3. RDON and AA are responsible for the implementation and monitoring of this corrective action. 4. This corrective action will be fully implemented by June 30, 2022.
Standard #:	22VAC40-73-680-E
Description:	Based upon observations, documentation and an interview, the facility failed to ensure one of two residents' treatments were administered as ordered. Evidence: 1. On 5/9/2022, the LI conducted medication administration observations with staff 2 for resident 2. During the medication pass, staff 2 stated she could not find the Triamcinolone Acetonide cream for resident 2 in the medication or treatment cart and she stated, "It was almost empty yesterday so staff must have thrown it away." Staff 2 did not apply the cream to resident 2. 2. Resident 2 (admitted 4/24/2022) had a physician's order (signed 4/14/2022) for Triamcinolone Acetonide topical cream apply a thin layer twice a day to affected area. 3. The April and May MAR listed "Triamcinolone Acetonide 0.1% crm jar, apply a thin layer to the affected area(s) 2 times daily starting 4/25/2022." The times listed were 9:00 am and 4:00 pm. 4. The April medication administration record (MAR) was initialed and circled for 4:00 pm on 4/26/2022; 9:00 am and 4:00 pm on 4/27/2022 and 4/28/2022; 9:00 am on 4/29/2022 and 4/30/2022. The omission notes listed were: "Physically unable to take. Not here from pharmacy yet. Not on the cart. Waiting for medication." 5. On 5/9/2022, the LI interviewed the nurse on duty who stated the cream was not on site but had been ordered and would be delivered in the evening.
Plan of Correction:	1. On 05/09/2022, the treatment was ordered and delivered by the pharmacy that evening. MARs was reviewed by AA and RMA on duty on 05/13/2022 and confirmed that resident has been receiving treatment as ordered. 2. Wellness Coordinator will be conducting weekly audits of the medication administration records to ensure proper administration of both medications and treatments. RDON will be notified immediately of any noncompliance. RDON will review medication cart every other week for compliance. AA is scheduled to begin RMA training on 07/11/2022. 3. Wellness Coordinator, RDON and AA are responsible for the implementation and monitoring of this corrective action. 4. This corrective action will be fully implemented by May 16, 2022.
Standard #:	22VAC40-73-860-G
Description:	Based upon observations and interviews, the facility failed to ensure the hot water temperature remained between 105 to 120 degrees Fahrenheit (F). Evidence: 1. On 5/9/2022, the LI conducted interviews with residents 1 and 2 and both residents stated the water temperature was fine, that it gets hot but they can adjust it. 2. On 5/9/2022, the LI tested the hot water temperature in the bathroom sink of room N-8 and the temperature reached 124.9 degrees F.
Plan of Correction:	1. On 05/09/2022, AA contacted Maintenance Director (MD) to check the water temperature and adjust accordingly. Maintenance schedule indicates that April 2022 reading was 110 degrees. MD reported on 05/10/2022 that he took two readings (one in the back of the building and one in the front) measuring 117 and 119 degrees. Temperature was turned down 2 degrees and reads 114 and 116 degrees on 05/13/2022. 2. Weekly readings to be obtained by MD for the next month. If all readings remain below 120, then community will return to monthly temperature measurements. 3. MD is responsible for the implementation and monitoring of this corrective action and will report any areas of ongoing noncompliance to the AA. 4. This corrective action will be fully implemented by May 16, 2022.
Standard #:	22VAC40-73-970-A
Description:	Based upon documentation, the facility failed to ensure fire drills were conducted each shift in a quarter. Evidence: 1. The fire drill forms indicated fire drills on the 6:00 am to 2:00 pm shift were held 3/24/2021, 6/24/2021, 12/27/2021, 1/13/2022 and 4/26/2022. 2. The fire drill forms indicated fire drills on the 2:00 pm to 10:00 pm shift were held 4/29/2021, 5/26/2021, 7/28/2021, 8/31/2021, 9/22/2021, 10/29/2021, 11/15/2021 and 2/14/2022. 3. The fire drill forms indicated fire drills on the 10:00 pm to 6:00 am shift were held 2/26/2021 and 3/25/2022.
Plan of Correction:	1. AA was made aware of this issue in January 2022 by MD and corrective action was taken at that time. January fire drill was performed on first shift, February on second shift, March on third shift and April on first shift. The fire drill for May is scheduled for second shift during week of 05/23/2022. 2. No new measures are warranted at this time as corrective action was implemented in January 2022 and records indicate that we are in compliance since that time. 3. MD is responsible for the implementation and monitoring of this corrective action and will report any areas of ongoing noncompliance to the AA. 4. This corrective action will be fully implemented by May 16, 2022.
Standard #:	22VAC40-73-990-C
Description:	Based upon record reviews and an interview, the facility failed to ensure resident emergency procedures were reviewed with all staff at least once every six months. Evidence: 1. The only documented review on file for resident emergencies was completed on 2/17/2022. 2. On 5/10/2022, the LI interviewed the administrator who stated the training on 2/17/2022 was the only training she could find for resident emergencies in the past year.
Plan of Correction:	1. Interim Administrator (IM), Wency Chapnkem, identified this area of noncompliance in February and provided training on February 17, 2022. 2. AA to create a list of all training due dates to be reviewed monthly and scheduled in a timely manner to ensure compliance with this standard. Staff will be required to sign off on the training and a copy of this form will be kept in the compliance binder in AA's office. 3. AA is responsible for the implementation and monitoring of this corrective action. 4. This corrective action will be fully implemented by May 27, 2022.