VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Birch Gardens
12 Royal Drive
Staunton, VA 24401
(540) 886-5007

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Jan. 21, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Reminded the activities director that the posted activities calendar must accurately reflect the activities provided each day and that a permanent record of the activities calendar must be maintained on file at the facility for two years.

Comments:

An unannounced non-mandated inspection was conducted on 1/21/20 from 8:00 am to 9:40 am. The breakfast meal was observed and the posted menu accurately reflected this inspector's observations. The morning activity was also observed; however, the posted activities calendar did not accurately reflect this inspector's observations. Individual interviews were conducted with staff and residents. The area of noncompliance was in activities. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection.

Violations:

Standard #:	22VAC40-73-520-I
Description:	Based upon observations, documentation and an interview, the facility failed to ensure substitutions or changes were documented on the posted activities calendar. Evidence: 1) On 1/21/20, the licensing inspector (LI) observed Bingo being held at 9:30 am. 2) The activities calendar indicated from 9:30 am to 10:30 am "Coffee and Reminiscing" and 2:00 pm to 3:00 pm "Bingo." 3) On 1/21/20, the LI interviewed the activities director who stated she had switched the activities; however, she stated she had not documented the change on the posted calendar. Interviews with staff and residents also indicated activities were changed and often the same few activities were offered throughout the month; however, the activities calendar did not indicate these changes.
Plan of Correction:	The activities director has completed an audit of the activities calendar and fixed all times for activities. Activities director or designee will review the calendar each day to ensure accuracy of activities for the day and record any changes, additions or substitutions. The administrator will review the activities calendar five times a week to ensure it reflects the activities provided for the residents. The administrator will be responsible for compliance with this standard.