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: Jan. 30, 2023 and Jan. 31, 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 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 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Technical Assistance:

1. Ensure timeframes required by the standards are followed and that information is obtained/completed within those timeframes. 2. Recommended the monthly resident council meetings be included on the activities calendar. 3. Review of the fire, emergency preparedness and infection control plans and renewal of the limited liability insurance are due by the end of March 2023. 4. Food consumption logs need to be completed after each meal and not at the end of the shift. 5. Ensure all policies are current and send all changed/updated policies to this inspector for review.

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: 1/30/2023 from approximately 7:00 am to 10:00 am, 12:00 noon to 7:00 pm and 1/31/2023 from approximately 7:10 am to 6:50 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: 27 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 Number of staff records reviewed: 4 + selected sections of 2 additional staff records Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 + 1 collateral Observations by licensing inspector: Meals, medication administration, medications, medication carts, emergency food supply, first aid kit, staffing, communication logs, food consumption logs, postings, etc. 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 #:	22VAC40-73-40-B-3
Description:	Based upon documentation and an interview, the facility failed to ensure one of fourteen staff had a criminal record report (CRR) completed within 30 days of hire. Evidence: 1. Staff 5 (hired 10/1/2022) had a CRR dated as completed 1/30/2023. 2. On 1/31/2023, the LI interviewed the administrator who stated staff 5 started working on 10/15/2022 and the CRR had not been completed until 1/30/2023.
Plan of Correction:	The administrator obtained all missing CRRs. The administrator will ensure all CRR paperwork is completed, checked and immediately mailed at the time when the pre-hire paperwork is completed, prior to starting work. The administrator will be responsible to ensure all CRRs are obtained prior to hire and no later than within 30 days of hire to ensure compliance with this standard.
Standard #:	22VAC40-73-250-D
Description:	Based upon documentation and an interview, the facility failed to ensure one of five tuberculin (TB) skin tests/assessments was completed within seven days of hire. Evidence: 1. Staff 5 (hired 10/1/2022) had an initial TB skin test completed on 10/4/2022. 2. On 1/31/2023, the LI interviewed the administrator who stated this TB test was the only test on file for staff 5.
Plan of Correction:	The administrator will maintain a log as a monitoring tool to document the TB screening of each new employee hired to ensure that the test is performed on or within seven days prior to the first day of work. The administrator will ensure the TB test has been read and is negative prior to the employee?s start date.
Standard #:	22VAC40-73-260-A
Description:	Based upon documentation and an interview, the facility failed to ensure one of five staff completed first aid (FA) within 60 days of hire. Evidence: 1. Staff 1 (hired 9/30/2022) did not have documentation on file for completion of FA training. 2. On 1/31/2023, the LI interviewed the administrator who stated staff 1 had not completed FA training. 3. On 1/31/2023, the LI interviewed staff 1 who stated she had completed the training at another facility, however, it expired.
Plan of Correction:	The administrator will complete a 100% staff chart audit to ensure compliance. Administrator will develop a spreadsheet that includes employee?s expiration dates of cardiopulmonary resuscitation (CPR) and FA. Administrator will audit the spreadsheet monthly to ensure employees are scheduled for the class at least one month prior to the expiration dates in order to ensure continued compliance
Standard #:	22VAC40-73-260-C
Description:	Based upon observations, documentation and an interview, the facility failed to ensure the FA and CPR posted list was kept current. Evidence: 1. On 1/30/2023, during the facility tour, the LI observed the posted list of staff with FA/CPR. The date at the bottom indicated the list was last updated on 8/23/2022. 2. On 1/30/2023, the LI interviewed the administrator who stated the FA/CPR list had not been updated since she had been the administrator. 3. Of the five staff records reviewed, staff 5 had completed FA/CPR and was not on the posted list for staff with current FA/CPR certifications.
Plan of Correction:	An updated FA/CPR list was posted on the day of inspection. The administrator updated the FA/CPR employee list and will update the list each time an employee is hired who has current certification, when a new employee obtains certification and when an employee who has certification leaves. The administrator will update the list with each change of staff and will ensure the posted list remains current at all times.
Standard #:	22VAC40-73-520-E
Description:	Based upon observations and interviews, the facility failed to ensure at least 14 hours of activities were held each week with no less than one hour each day. Evidence: 1. On 1/30/2023, the LI did not observe any activities occurring throughout the day. 2. On 1/30/2023, the LI interviewed residents 3 and 6 and staff 3. All three stated they have activities two to three times a week now.
Plan of Correction:	The administrator delegated the morning (6:00 am to 2:00 pm) direct care staff to conduct one hour of activities daily at 10:00 am. The 2:00 pm to 10:00 pm direct care staff will conduct one hour of activities daily at 3:00 pm until an activities director is hired. An activities director was hired on 2/15/2023 and will start work on 3/1/2023. Administrator and direct care staff will ensure 14 hours of activities are being done each week.
Standard #:	22VAC40-73-520-I
Description:	Based upon observations and an interview, the facility failed to ensure a written schedule of activities was posted. Evidence: 1. On 1/30/2023, the LI conducted a tour of the facility and an activities calendar was not observed posted on any bulletin board or anywhere in the facility. 2. On 1/30/2023, the LI interviewed the administrator who stated since the activities staff left she had not created or posted an activities calendar.
Plan of Correction:	The administrator created an activities schedule and posted it. The administrator will ensure the activities schedule is posted and up to date. Once the activities director starts, she will take over the responsibility of creating the activities schedule and keeping the posted activities schedule up to date. The administrator will conduct at least weekly checks and will be responsible for ensuring 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 1/30/2023, the licensing inspector (LI) observed the breakfast and lunch meals and a glass of orange juice for breakfast was the only fruit observed being provided to the residents. 2. The posted menu for the week of 1/30/2023 to 2/5/2023 listed the following fruits: orange juice served for breakfast every day, fruit cocktail at lunch on 2/2/2023, and peaches at dinner on 2/5/2023. The menu listed only two servings of vegetables on 1/30/2023 and 2/4/2023. 3. On 1/30/2023, the LI interviewed the cook who stated they had no fruit to serve as none had been ordered. 4. On 1/30/2023, the LI checked the area where food was stored and there were no cans of fruit on the shelves, cabinets or in the refrigerators.
Plan of Correction:	The administrator will work with dietary staff to ensure the menus meet the USDA food guidance system. The administrator and dietary staff will ensure two servings of fruit and three servings of vegetables are being served daily, along with the other recommended servings for the other food groups. The administrator will review the menu the week prior to posting to ensure compliance. The administrator will be responsible for monitoring the menus and meals for 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.
Plan of Correction:	The administrator and corporate team will ensure we have contracts and dietary oversights completed every six months. Corporate sent new dietary contract on 1/31/2023. Dietician came out on 2/9/2023 and completed the dietary oversight. The administrator will ensure a dietary oversight is completed for all special diets every six months. The administrator will review the dietician?s report and ensure it meets all requirements of this standard. If the contract is cancelled at any time, a new contract will be obtained in a timely manner to ensure continued compliance with this standard.
Standard #:	22VAC40-73-640-A
Description:	Based upon documentation, the facility failed to implement the facility medication management plan by not ensuring medications were ordered and available to avoid missed doses for two of two resident medication administration records (MARs) reviewed. Evidence: 1. Page 160 6.a and b. of the facility medication management plan states, ?A notebook shall be maintained to assure accurate and timely communication with the pharmacy regarding new orders, refills, and medication discrepancies/concerns, etc. Pharmacy communications will be logged with initials, date and time to avoid duplication. Evening and night shifts should log requests for refills, and other non-emergency communications that will then be called into the pharmacy by the oncoming day shift med aide. Therefore, day shift med aide will check the pharmacy communication notebook each morning at the start of shift. If a medication is not available at the scheduled time of administration, the pharmacy will be notified, an entry will be made in the pharmacy communication notebook, and the supervisor will be notified. Charting ?med not available? on the MAR alone, does not fulfill this requirement.? 2. Page 162, 8.b and c. of the facility medication management plan states, ?All medication staff are responsible for monitoring the need for refills. It shall be the responsibility of the night shift medication aide or nurse to check all medications to include PRN medications and private pharmacy medications twice a week to see if refills are needed.? 3. Resident 1 had as needed (PRN) physician?s orders signed on 1/17/2023 for Biofreeze and Nystatin Powder and on 1/3/2023 for Refresh Tears. 4. On 1/30/2023, the LI and staff 1 conducted a medication cart audit and these medications were not in the cart or available on site. 5. Resident 2 had a renewed physician?s order signed 1/11/2023 for Pantoprazole, one 180mg tablet twice a day. 6. The MAR for resident 2 was initialed and circled on 1/7/2023, 1/13/2023 - 1/15/2023, 1/18/2023, 1/21/2023 ? 1/25/2023, 1/27/2023 ? 1/29/2023 for 7:00 am and 4:00 pm; 1/10/2023, 1/11/2023, 1/16/2023, 1/19/2023, 1/20/2023 and 1/26/2023 for 4:00 pm; and 1/30/2023 for 7:00 am. The notes for not administering the medication stated, ?Physically unable to take.? 7. On 1/30/2023, the LI interviewed staff 1 and the administrator and both stated the medication was not administered as it was not available on site and the only suitable option to select on the MAR was ?Physically unable to take.?. 8. Resident 2 had a physician?s order signed 10/26/2022 for Senna Lax two 8.6mg tablets at bedtime. 9. The MAR was circled and initialed on 1/19/2023 ? 1/22/2023, 1/24/2023 ? 1/25/2023 and 1/27/2023. The notes indicated, ?Physically unable to take.? 10. On 1/30/2023, the LI and the administrator conducted a check of the medication cart and the card for the Senna Lax for resident 2 was found in the bottom drawer of the cart with the PRN medications. 11. Resident 2 had PRN orders signed on 12/20/2022 for Azelastine nasal spray and Benzonatate for cough. 12. During the medication cart audit the PRN Azelastine and Benzonatate for resident 2 were not in the cart or available on site.
Plan of Correction:	Signed orders were obtained and sent to the licensing inspector. Pantoprazole was received from pharmacy and is now being administered per order signed 2/5/2023. The administrator and wellness coordinator will conduct monthly medication cart audits to ensure all medications are available. Night shift registered medication aide (RMA) will also do a medication cart audit on the monthly change over cycle to ensure all medications are available. The administrator will keep log of all medication cart audits and the staff that performed them. The administrator will actively monitor these medication cart audits to ensure all medications are available and to ensure compliance with this standard.
Standard #:	22VAC40-73-980-H
Description:	Based upon observations and an interview, the facility failed to ensure at least a 96-hour supply of emergency food was available with 48 hours being on site. Evidence: 1. On 1/30/2023, the LI observed the food storage area, refrigerators and freezers and there was no canned/frozen/fresh fruit, canned/frozen/fresh vegetables and no canned/frozen precooked meats on site to serve in case of an emergency. 2. On 1/30/2023, the LI interviewed staff 7 who stated they did not have any emergency food on site.
Plan of Correction:	The administrator and dietary staff will work together to ensure a 96-hour supply of emergency food is on hand at all times. The administrator and dietary staff will log monthly food checks to ensure a 96-hour supply of food is on hand. The administrator will be responsible for compliance with this standard.