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: July 28, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Recommended all staff be in-serviced on end of life care and registered medication aides be in-serviced on the use of the electronic medication administration record and what to do if they suspect or see a documentation error.

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/28/2022 from approximately 9:52 am to 12:00 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 7/27/2022 regarding allegations in the area of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 35 Number of resident records reviewed: 1 Number of staff records reviewed: 11 (only selected sections) Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 10 Observations by licensing inspector: Staff, resident and family interactions; staff providing care to residents Additional Comments/Discussion: Reviewed medication administration records and signed physician?s orders An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were in the areas of resident care, medication administration documentation and medication administration. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-450-H
Complaint related:	Yes
Description:	Based upon documentation and interviews, the facility failed to ensure the care and services specified in the individualized service plans (ISPs) were provided to one of two resident records reviewed. Evidence: 1. The ISP (signed as completed on 7/8/2022) for resident 1 listed daily oral care and to swab resident?s mouth as needed. 2. On 7/28/2022, the licensing inspector (LI) interviewed staff 1, 6, and 11 and all three staff stated they did not provide oral care to the resident or swab her mouth on 7/8/2022 or 7/9/2022 while they were on duty. 3. There was no mutually agreed upon deviation from the ISP documented in resident 1?s record and according to the legal representative interviewed on 7/27/2022.
Plan of Correction:	All direct care staff have been in-serviced by the regional director of nursing on following the ISP provided for all residents. Biweekly this compliance will be reviewed and monitored by shadowing the direct care staff team by the wellness coordinator and or designee to ensure accuracy of following the ISP for each resident?s care needs.
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based upon documentation and interviews, the facility failed to ensure one resident?s medications were administered according to the physician?s orders. 1. Resident 1 had physician?s orders signed 7/8/2022 for oxycodone concentrate 0.25ml (5mg) by mouth PRN every hour for pain/moaning and Lorazepam Intensol 0.25ml (0.5mg) by mouth PRN every four hours for anxiety. 2. On 7/9/2022 at 2:30 am, staff 8 administered 0.50ml of oxycodone and 0.50ml of lorazepam. 3. Resident 1 had physician?s orders signed 7/8/2022 for Lorazepam Intensol 0.25ml (0.5mg) by mouth every four hours. 4. The MAR for resident 1 listed the administration times for the scheduled Lorazepam as 9:00 am, 1:00 pm, 5:00 pm and 9:00 pm. 5. The MAR for resident 1 had the initials for staff 8 for administering the Lorazepam at 9:00 am on 7/9/2022. 6. On 7/28/2022, the licensing inspector (LI) interviewed staff 8 who stated she ?would not have given the lorazepam at 9:00 am as her shift is from 10:00 pm to 6:00 am. 7. The staff schedule for 7/9/2022 indicated staff 3 was the medication aide on duty at 9:00 am on 7/9/2022. 8. On 8/11/2022, the LI interviewed staff 3 who stated she did not administer the 9:00 am dose of Lorazepam as the MAR was already signed off by another staff.
Plan of Correction:	A one hundred percent audit is being conducted of all residents? medications to ensure accuracy of administration. Each registered medication aide has been in-serviced on the importance of following the orders provided by the physician for each resident. Each medication aide will have one medication pass observed to ensure they are following the orders as prescribed. The wellness director or designee will conduct biweekly audits and observations of the MARs and medication passes to ensure accuracy.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based upon documentation, the facility failed to ensure the medication administration record (MAR) for one resident included all required documentation. 1. Resident 1 had physician?s orders signed 7/8/2022 for oxycodone concentrate 0.25ml (5mg) by mouth PRN every hour for pain, moaning and Lorazepam Intensol 0.25ml (0.5mg) by mouth PRN every four hours for anxiety. 2. The narcotic count sheets for resident 1 indicated oxycodone was administered on 7/9/2022 at 4:10 am, 9:00 am and 1:00 pm and lorazepam was administered on 7/9/2022 at 4:10 am and 1:00 pm; however, administration of these PRN medications were not documented on the MAR.
Plan of Correction:	All registered medication aides were in-serviced on the importance of accurate documentation on the MAR. Each medication aide will have one medication pass observed by the regional director of nursing with suggestions made to enhance and ensure compliance with accurate documentation of each medication administered. The wellness director or designee will conduct biweekly audits of the MARs to check for accuracy in documentation.