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: June 27, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS

Technical Assistance:

Reminded administrator and wellness nurse to carefully review the medication administration record along with the physicians? orders immediately upon admission (or prior to if possible) to ensure all information is included and is accurate and complete.

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/27/2022 from approximately 11:45 am to 3:00 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 (only selected sections) Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Additional Comments/Discussion: Reviewed selected sections of four medication administration records, physician?s orders and medications. 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 #:	22VAC40-73-70-B
Description:	Based upon documentation and an interview, the facility failed to ensure a stage 2 wound was reported to the licensing office. Evidence: 1. Resident 4 (admitted 6/14/2022) had an admission progress documented by staff 1 on 6/14/2022 which stated, ?Resident is currently bed bound and has a stage II pressure sore on her coccyx. Also on upper right thigh.? 2. The major incident report was submitted to this licensing inspector (LI) by the administrator during this inspection on 6/27/2022. 3. On 6/27/2022, the LI interviewed the administrator and she stated she meant to send this report and knew she was supposed to but just had not completed it.
Plan of Correction:	1. Facility reported incident (FRI) for Resident 4 was completed and submitted on 06/27/2022. All new admissions within the past 60 days were reviewed by the administrator on 06/28/2022 and found to be in compliance with the standard. 2. Training will be provided to all staff at next staff meeting scheduled for 07/07/2022. The district nurse will review documentation of all new admissions and report any major incident to the administrator immediately. 3. The administrator is responsible for the implementation and monitoring of this corrective action. 4. This corrective action will be fully implemented by July 7, 2022.
Standard #:	22VAC40-73-680-I
Description:	Based upon documentation, observations and interviews, the facility failed to ensure all medications administered to one of four residents were documented on the medication administration record (MAR). Evidence: 1. Resident 4 (admitted 6/14/2022) had signed physician?s orders dated 6/9/2022 for as needed oxygen and Aspercreme. 2. On 6/27/2022, the LI interviewed resident 4 and observed oxygen in use; however, resident 4 stated she has never needed the Aspercreme or asked for it. 3. The June 2022 MAR for resident 4 did not list the oxygen or the Aspercreme.
Plan of Correction:	1. The district nurse contacted the pharmacy to add orders for oxygen and Aspercreme to the MAR. Administrator reviewed MAR on 06/29/2022 and confirms that both were added on 06/27/2022. 2. The district nurse and wellness coordinator met with administrator on 06/28/2022 and will complete a full review of all MARs to ensure compliance with the physicians? orders. The third shift RMA will be tasked with performing weekly audits of the MAR and report any areas of noncompliance with the district nurse immediately. 3. The district nurse is responsible for the implementation and monitoring of this corrective action. 4. This corrective action will be fully implemented by July 15, 2022