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: Feb. 16, 2024

Complaint Related: No

Areas Reviewed:

Administration and Administrative Services Personnel Staffing and Supervision Admission, Retention and Discharge of Residents Resident Care and Related Services Buildings and Grounds Emergency Preparedness Mixed Population

Comments:

Date of Inspection: February 16, 2024 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 21 Number of records reviewed and interviews conducted- 6 records (staff and resident), 7 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during meals and individual activities. The Licensing Inspector reviewed the following at the time of inspection: menus, activity calendars, dietician report, fire drills, pharmacy review and healthcare oversight. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations:

Standard #:	22VAC40-73-450-F
Description:	Based on resident record review and staff interview, it was determined that the facility failed to update an Individualized Service Plan (ISP) annually as required. Evidence: Resident B had no current documentation on the ISP of an annual review. The last ISP was dated April 9, 2022.
Plan of Correction:	All resident records will be audited by the Administrator. All ISPs will be current in the record as required.