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: April 22, 2024

Complaint Related: No

Areas Reviewed:

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

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: 4/22/2024 3:00pm - 4:00pm A self-reported incident was received by VDSS Division of Licensing on 4/19/2024 regarding allegations in the area(s) of Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 32 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: N/A The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jessica Gale, Licensing Inspector at 540-571-0358, or by email at jessica.gale@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-130-A
Description:	Based on record review, staff, and collateral contact interviews, the facility failed to report an incident in accordance with the Code of Virginia. Evidence: 1. An incident occurred at the facility on 4/19/2024 between 2 residents. 2. Staff 1 was interviewed and stated that a report was not sent to APS until 4/21/2024. 3. An interview with a collateral contact was conducted and confirmed that the incident report was emailed by the facility to another state agency on 4/21/2024 and then forwarded by that agency to the collateral contact on 4/22/2024. 4. A record review for staff 1 and staff 2 confirmed receipt and signature of the Virginia Legal Requirements to Report Abuse, signed by staff 1 on 3/11/2024, and staff 2 on 4/15/2024.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-300-B
Description:	Based on record review and staff interviews, the facility failed to utilize written communication to inform all shifts of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. Evidence: 1. Following an incident that occurred at the facility on 4/19/2024 at 1:00pm, an incident report was received by the Virginia Department of Social Services (VDSS) on 4/19/2024 at 4:49pm stating, following the incident ?both residents have been put on 30-minute checks for the next 24 hours.? 2. Following review of the facility Shift Communication Log dated 4/19/2024 and the resident record for residents 1 and 2, there is no evidence of instruction for or completion of 30-minute checks for resident 1 nor resident 2. 3. Following an interview with staff 2, staff 2 stated ?they didn?t do them?.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review and interviews with staff, the facility failed to update the Individualized Service Plan (ISP) to reflect admission to Hospice Services. Evidence: 1. Following review of resident records, resident 1 was admitted to hospice services on 3/4/2024. The ISP dated for 7/12/2023 was not updated to reflect the admission to hospice services. 2. An interview was conducted with Staff 1 who confirmed that the ISP had not been updated to reflect admission to hospice services.
Plan of Correction:	Not available online. Contact Inspector for more information.