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Public Google reviewers rate this highly and often mention compassionate and attentive care staff. Schedule a visit to confirm the fit.
based on 13 Google reviews
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Public Google reviewers rate Birch Ridge (augusta Co) highly. Reviewers highlight: compassionate and attentive care staff, exceptional administrative leadership. Reviewer identity is not verified, and online reviews may not capture everything. Schedule a visit to assess the fit directly.
Families considering Birch Ridge can expect a highly compassionate environment, with multiple reviewers specifically praising the administrator and staff for their attentive, person-centered care. While the facility is noted for its beautiful scenery and home-like atmosphere, there are isolated instances of very low satisfaction that should be investigated.
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Key Review Excerpts
“Amber Fortenberry, the Administrator of Birch Ridge is fantastic! She cares so much about my Dad's well being and has been very very helpful to my Dad and to me, his son.”
“After calling and visiting nearly every assisted living facility in the area—with no luck—I felt completely deflated. Places were either too expensive, unequipped for dementia care, poorly maintained, or simply gave me bad vibes (always trust your intuition).”
“I can't say enough good things about the ladies that took care of my dad. Although his stay here was rather short, the staff and Amber went over and above themselves to ensure that his final days were enjoyable and comfortable.”
Source: VA State Licensing Agency
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: February 24, 2026, from 10:25 a.m. until 5:00 p.m. 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: 18 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: The Licensing Inspector toured the community and observed the residents during activities and meals. The Licensing Inspector reviewed the following at the time of inspection: sample of resident and employee records, medication administration, fire drills, emergency drills, pharmacy review, menus, activity calendars, verified appropriate amount of liability insurance, and dietician report. Additional Comments/Discussion: None 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. 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). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem-solving conference. 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 Angie Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Based on resident record reviews and staff interviews, the facility failed to obtain a physical examination by an independent physician within 30 days preceding admission with recommendations for care, including medications. Evidence: 1. The admission date for resident 1 was 01/24/2026. The date of the face-to-face physical examination for resident 1 was 01/24/2026, which did not include a medication list signed by the physician as required. 2. Staff 4 and 5 acknowledged that the physical examination report for residents 1 was not completed according to the standard.
Based on resident record reviews and staff interview, the facility failed to ensure risk assessments for tuberculosis (TB) were completed annually. Evidence: 1. Record for resident 3, admission date 07/19/2019, was reviewed. A TB screening for 2025 was not in the record. 2. Staff 5 acknowledged that the TB screening had not been completed on an annual basis.
Based on resident record review and staff interviews the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and document in the resident's record the date this information was ascertained. Evidence: 1. Record for resident 2, admitted 02/02/2026, did not contain a registered sex offender search. 2. During an interview with the LI on 02/24/2026, staff 5 confirmed the registered sex offender search for resident 2 was not completed prior to admission.
Based on facility record review and staff interview, the facility failed to ensure fire drills were completed on each shift in a quarter in accordance with the Virginia Statewide Fire Prevention Code (13VAC5-51). Evidence: 1. During a record review on 02/24/2026, the LI observed that fire drills were conducted 07/17/2025 on 6 a.m. to 6 p.m. shift, 08/17/2026 on 6 a.m. to 6 p.m., and 09/24/2025 on 6 a.m. to 6 p.m. shift. No fire drills were completed during 6 p.m. to 6 a.m. shift from July 2025 through September 2025. 2. Staff 5 confirmed that fire drills were not completed on each shift during the quarter as required.
Based on document review and staff interview, the facility failed to ensure at least once every six months staff on duty on each shift participated in an exercise in which procedures for resident emergencies were practiced. Evidence: 1. On 02/24/2026, LI requested documentation of practice exercises for resident emergencies. 2. No resident exercises for medical or mental emergencies were practiced. 3. On 02/24/2026, staff 5 acknowledged that staff did not participate in medical and mental emergencies.
Based on direct observation and staff interview, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge, as provided for in this chapter, in the facility that was conspicuous to both residents and the public. Evidence: 1. During the facility tour completed on 02/24/2026, the licensing inspector (LI) observed the current staff person in charge posted in the facility for the previous day, 02/23/2026. 2. During an interview on 02/24/2026 with the LI, staff 5 stated that the person in charge was not updated for the current day and still showed the previous day, 02/23/2026. 3. Photo evidence taken.
Based on resident record review and staff interviews, the facility failed to ensure a complete first aid kit was on hand at the facility and contained items with expiration dates that had not already passed. Evidence: 1. The facility first aid kit was inventoried by LI on 02/24/2026. The first aid kit contained Curad petrolatum dressings which expired 01/2023 and 07/23/2025 respectively, Curad xeroform petrolatum dressings which expired 10/2023, antimicrobial skin cleanser which expired on 09/2023, saline wound wash which expired on 12/2017, Skintegrity wound cleanser which expired on 09/2024, and dermal wound wash which expired on 08/2025. 2. During an interview with the LI on 02/24/2026, staff 5 acknowledged the Curad petrolatum dressings, Curad xeroform petrolatum dressings, antimicrobial skin cleanser, saline wound wash, Skintegrity wound cleanser, and dermal wound wash were all expired. 3. Photo evidence taken.
Based on resident record review and staff interview the facility failed to ensure that the preliminary plan of care was developed to address the basic needs of the resident to adequately protect the health, safety, and welfare of the resident. Evidence: 1. Record for resident 1, admitted 01/24/2026, did not contain a preliminary plan of care that addressed behaviors identified in the UAI
Based on observation and staff interview, the facility failed to store cleaning supplies in a locked area. Evidence: 1. During a tour of the facility on 02/24/2026, LI observed an unlocked laundry room containing cleaning liquids, including Clorox spray, Clorox disinfecting wipes, Pledge, Fabuloso, Windex, furniture polish, and Xtra laundry detergent. 2. During an interview with the LI on 02/24/2026, staff 5 confirmed the laundry room was unlocked when LI toured and should have been secured. 3. Photo evidence taken.
Based on staff record review and staff interview, the facility failed to ensure documented absence of tuberculosis in a communicable form as evidenced by completion of the current screening form published by the Virginia Department of Health or a form consistent with it, on or within seven days prior to the first day of work at the facility. Evidence: 1. Record for staff 2, hired 11/17/2025, did not contain a tuberculosis (TB) risk assessment, which was required on or within seven days prior to the first day of work at the facility. 2. Staff 5 acknowledged that the TB risk assessment for staff 2 was not completed on or within seven days prior to the first day of work at the facility.
Based on resident record reviews and staff interview, the facility failed to complete a Uniform Assessment Instrument ( UAI
Based on resident record review and staff interview the facility failed to ensure that a fall risk rating was completed by the time the comprehensive ISP
Based on facility record review and staff interview, the facility failed to ensure the semiannual review of the emergency preparedness plan for all staff, residents, and volunteers included all six elements of this subsection with the review documented by signing and dating. Evidence: 1. LI requested the semi-annual review of the emergency preparedness and response plan for staff, residents, and volunteers. 2. During document review on 02/24/2026, the LI observed the semiannual review of emergency preparedness with staff and residents only occurred once in 2025. 3. Staff 5 confirmed the reviewed emergency preparedness and response trainings only occurred once on 04/30/2025, not twice as required.
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 9/15/2025 regarding allegations in the area(s) of: staffing and supervision and Resident Care and Related Services. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/16/2025 10:00 a.m. ? 11:41 a.m. 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: 20 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: The licensing inspector reviewed staff communication, the staff schedule, fall risk rating, and facility video footage. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the complaint of non-compliance with standard(s) or law, and violation(s) were 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Based on observation and staff interview, the facility failed to ensure there were at least two direct care staff members awake and on duty at all times. Evidence: 1. This facility contained a mixed population of residents. 2. A complaint was received by the regional licensing office on 9/15/2025 indicating that resident 1 had fallen and was left on the floor for greater than 20 minutes initiating a call to local emergency medical services for assistance. 3. Personnel from the emergency medical services (EMS) were interviewed regarding the incident and stated that upon entry to the facility at 12:30 a.m. on 9/13/2025 there were no staff present upon entry, the EMS responders searched through the facility for resident 1 and located them in their apartment on the floor. Once the resident was assisted the EMS responders searched the facility and found staff 3 and 4 asleep in the staff area and EMS responders woke them. 4. Video footage was observed during the inspection and revealed staff 3 and staff 4 both asleep from 12:30 a.m. until 12:45 a.m. when EMS woke them, and again from 4:22 a.m. - 5:16 a.m. 5. The staff schedule was reviewed and confirmed that staff 3 and staff 4 were the only staff on duty. 6. During an interview with staff 1 and staff 2 when asked if there were any other staff present on the night shift of 9/12/2025 through 9/13/2025 staff 1 stated ?no, just them?.
Based on record review and staff interview, the facility failed to ensure the Uniform Assessment Instrument ( UAI
Based on record review and staff interview, the facility failed to ensure individualized service plans ( ISP
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/29/2025 9:50 a.m. ? 10:05 a.m. 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: 20 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: The licensing inspector reviewed employee files and incident reports. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-reported incident 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Based on direct observation, record review, and staff interview, the facility failed to ensure that the facility was not operated by an acting administrator for more than 90 days. Evidence: 1. On 5/1/2025 the regional licensing office received a notification that staff 2 would be the acting administrator effective 5/1/2025. 2. On the day of the inspection, 8/29/2025, during an interview with staff 1, staff 1 confirmed that staff 2 was currently the acting administrator. 3. Staff 2 operated the facility as the acting administrator for a total of 120 days.
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 6/12/2025 regarding allegations in the area(s) of: Resident Discharge, Building and Grounds, Resident Care and Related Services, Incident Reporting, fall prevention. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/25/2025 12:15 p.m. ? 2:30 p.m. 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: 21 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: The licensing inspector toured the outside and entire of the facility including resident rooms, the licensing inspector observed residents in their rooms, in common areas, and during meals. The licensing inspector reviewed, incident reports, and staff schedules. Additional Comments/Discussion: None 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: 870-A, 870-B, 460-F, and 860-H. 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 DSSpublic 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Based on direct observation, the facility failed to ensure that where there was an outdoor area accessible to residents, such as a porch or lawn, that was equipped with furniture in season. Evidence: 1. During the facility tour on 6/25/2025, two licensing staff observed the front porch of the facility to have three rocking chairs with ripped and soiled cushions, and a rotting wooden side table. 2. Photo evidence taken.
Based on record review and staff interview, the annual reassessment, using the Uniform Assessment Instrument ( UAI
Based on record review and staff interview, the facility failed to ensure Individualized service plans ( ISP
Based on record review and staff interview, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls. Evidence: 1. Resident 1 (admitted 3/29/2024) had a total of 19 falls on the following dates, 1/27/2025, 1/30/2025, 2/11/2025, 3/5/2025, 3/6/2025, 5/10/2025, 6/14/2025 at 7:18 p.m.,8:10 p.m., 9:07 p.m. and 9:50 p.m., 6/15/2025, 6/16/2025 at 10:00 a.m., second fall on 6/16/2025 without a time documented), and 5:30 p.m., 6/18/2025 at 2:30 p.m., 5:50 p.m., 9:11 p.m., and 10:00 p.m., and 6/23/2025. 2. Record review for resident 1, had four fall risk ratings completed on 6/18/2025, four completed on 6/16/2025, one completed 6/15/2025, four completed on 6/14/2025, one completed on 5/10/2025, one completed on 3/6/2025, one completed on 3/5/2025, one completed on 2/11/2025, one completed 1/27/2025, all indicating resident 1 was a high risk for falls. 3. The ISP
Based on record review and staff interview, the facility failed to notify the next of kin, legal representative, or designated contact person of a resident falling. Evidence: 1. Resident 1 (admitted 3/29/2024) had 19 ?Unusual Occurrence Incident Reports? following each of resident 1?s falls. 2. 10 of 19 incident reportsindicated ?no? family notification with reason listed as ?didn?t have access to resident chart to get phone number?. 3. During an interview with staff 2, when asked why the family was not notified for 10 of the incidents of resident 1 falling, staff 2 stated ?I did not have access to the charts they were in a locked office inaccessible to the staff?
Based on record review and staff interview, the facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or that threatened the life, health, safety, or welfare of any resident. Evidence: 1. A complaint received by the regional licensing office on 6/12/2025 alleged that on 5/10/2025 resident 1 (admitted 3/29/2024) fell and had a head injury requiring stitches, and on 6/4/2025 and 6/6/2025 resident 1 was sent to the hospital for evaluation following mental health emergencies. 2. Record review for resident 1 contained documentation of resident 1 being sent to the hospital on 5/10/2025 for a fall with injury and on 6/4/2025 and 6/6/2025 following a mental health emergency. 3. During an interview with staff 1, when asked if an incident report was sent for the incidents with resident 1 that occurred on 5/10/2025, 6/4/2025, and 6/6/2025, staff 1 stated ?no?.
Based on direct observation the facility failed to ensure that the interior of the building was kept clean and the exterior of the building was maintained in good repair and kept free of rubbish. Evidence: 1. During the exterior tour on 6/25/2025, two licensing staff observed a broken flowerpot on the front porch, missing siding on the left side of the building showing exposed plywood, a broken recliner in the grass on the back of the building, and a broken rocking chair in the resident courtyard. 2. During the interior tour on 6/25/2025, the bathroom of resident room, North one, had feces in and around the lid and base of the toilet, a soiled brief in the trashcan, and a dried brown stain on the floor. 3. Photo evidence taken.
Based on direct observation, the facility failed to ensure the facility was free from foul odors. Evidence: 1. Upon entering resident room North one, two licensing staff observed a strong urine odor. 2. While in the room at 12:45 p.m. two licensing staff observed a soiled brief in the bedroom trashcan. 3. During an interview with staff 3 when asked how long the brief had been in the trashcan, staff 3 stated ?since breakfast time? 4. Photo evidence taken.
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 4/17/2025 regarding allegations in the area(s) of: Resident Care and Related Services, activities, meals, call bell response time, building and grounds. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/10/2025 10:15 a.m. ? 1:09 p.m. 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: 22 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: The licensing inspector observed residents in common areas, in their apartments, and during meals. The licensing inspector reviewed the menu, meal consumption logs, and activity calendars. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint 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. 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Based on direct observation the facility failed to store cleaning supplies and other hazardous materials in a locked area. Evidence: 1. During the facility tour on 6/10/2025, two licensing staff observed the laundry room door open and unlocked containing the following cleaning supplies; five containers of liquid laundry detergent, three containers of Pine Glo cleaner, five containers of Comet with Bleach cleaner, two bottles of furniture polish, one container of Fabuloso cleaner, one container of bathroom cleaner, one container of Clorox disinfecting wipes, and one gallon of bleach. 2. Photo evidence taken.
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: 1/16/2025 10:00am-3:10pm, 1/17/2025 10:00am-1:30pm. 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: 18 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: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: The licensing inspector observed residents during meals, in common areas, and in their apartments. The facility fire drills, emergency drills, health care and dietary oversight, health and fire inspections were reviewed. Additional Comments/Discussion: None 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov
Based on record review and staff interview, the facility failed to ensure direct care staff are trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. Evidence: 1. During a record review on 1/16/2025, resident 2, admitted 12/17/2024, had a UAI
Based on direct observation and upon request, the facility failed to ensure there is a copy of a diet manual containing acceptable practices and standards for nutrition, kept current, and readily available to personnel responsible for food preparation. Evidence: 1. During the facility tour on 1/17/2025, there was no dietary manual present in the kitchen. 2. Upon request on 1/17/2025, the facility did not provide a dietary manual.
Based on record review and staff interview the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility, submit the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. Upon request on 1/16/2025, the facility did not provide the results of a risk assessment documenting the individual is free of tuberculosis for staff 3 hired 4/16/2024 2. During an interview with staff 1 on 1/16/2025, when asked if there was a TB risk assessment completed for staff 3, staff 1 answered no.
Based on record review, the facility failed to ensure that the individualized service plan ( ISP
Based on record review and staff interview, the facility failed to develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. Evidence: 1. During the inspection on 1/16/2025, the facility did not provide a semi- annual review of the emergency preparedness and response plan for all staff, residents, or volunteers. 2. During an interview with staff 1 on 1/16/2025, when asked if there was a semi-annual review of the emergency preparedness and response plan, staff 1 stated, ?I don?t think it was done?.
Based on direct observation the facility failed to implement a procedure for posting the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public Evidence: 1. Upon entrance to the facility on 1/16/2025 at 10:00am, the posted supervisor in charge was dated for 1/15/2025. 2. Photo evidence taken
Based on direct observation the facility failed to ensure the emergency fire and emergency evacuation drawing contained all required information. Evidence: 1. During the facility tour on 1/16/2025, the fire and emergency evacuation drawing did not contain a secondary evacuation route, areas of refuge, or assembly areas. 2. Photo evidence taken.
Based on record review, the facility failed to ensure that for each resident with an inability to use the signaling device, the inability was included in the resident's individualized service plan. Evidence: 1. During the inspection on 1/16/2025, staff 1 provided a list of 4 residents with an inability to use a signaling device, including resident 2. 2. The ISP
Based on record review and staff interviews the facility failed to ensure there were at least 14 hours of scheduled activities available to the residents each week for no less than one hour each day. Evidence: 1. During the inspection on 1/16/2025, staff 1 provided a calendar labeled ?January 2025? with one activity listed each day, without an indication of the hour or length of activity. 2. During an interview with staff 1, when asked how many scheduled hours of activities are conducted at the facility daily, and if there were 14 scheduled hours of activities weekly, staff 1 stated ?I?m not sure, and probably not?. 3. A group of three staff were interviewed regarding activities in the facility, when asked when the last activity occurred at the facility the staff answered a craft was done at Christmas?.
Based on record review and staff interview, the facility failed to ensure fire and emergency evacuation drill frequency and participation was completed in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5- 51). Evidence: 1. During the inspection on 1/16/2025, the facility did not provide documentation of any fire drills completed at the facility. 2. During an interview with staff 1, hired 11/20/2024, when asked when the last fire drill was completed staff 1 stated ?not since I?ve been here?.
Based on direct observation, the facility failed to store cleaning supplies and other hazardous materials in a locked area. Evidence: 1. During the facility tour on 1/16/2025, the laundry room door was not locked containing a gallon of laundry detergent beside the washing machine and a shelf of cleaning chemicals including three containers of Comet with bleach, six containers of Clorox disinfecting wipes, three containers of furniture polish, and a spray bottle of disinfectant cleaner. 2. Photo evidence taken.
Based on record review, the facility failed to ensure the written work schedule included the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time. Evidence: 1. The current work schedule posted at the time of inspection on 1/16/2025, did not indicate whomever is in charge at any given time. 2. During an interview with staff 1 on 1/16/2025, when asked if the schedule indicated who is in charge, staff 1 stated ?no, it doesn?t.?
Based on record review and staff interview the facility failed to ensure a current picture of each resident was readily available for identification purposes. Evidence: 1. During a record review completed 1/16/2025, resident 2, admitted 12/17/2024, did not have a picture or description in the resident record. 2. During an interview with staff 1 on 1/16/2025, when asked if there was a picture or description in resident 2?s record, staff 1 stated ?probably not?.
Based on record review and staff interview, the facility failed to ensure direct care staff training commenced no later than 60 days after employment. Evidence: 1. Upon request on 1/16/2025, the facility did not provide any training records for Staff 3 hired 4/16/2024. 2. During an interview with staff 1 on 1/16/2025, when asked if there was any record of direct care training including infection control, staff 1 stated ?not that I can find?.
Based on record review the facility failed to ensure the written Do Not Resuscitate (DNR) orders for withholding cardiopulmonary resuscitation (CPR) from a resident in the event of cardiac or respiratory arrest was included in the individualized service plan. Evidence: 1. Resident 1, admitted 10/31/2024, had a DNR order dated 11/13/2024. 2. The ISP
Based on record review, the facility failed to ensure all identified needs were included on the preliminary Individualized Service Plan ( ISP
Based on direct observation and staff interviews, the facility failed to ensure the current month's written schedule of activities was posted in a conspicuous location in the facility or otherwise be made available to residents and their families. Evidence: 1. During the facility tour on 1/16/2025, there was no schedule of activities posted in the facility. 2. During an interview with staff 1 on 1/16/2025, when asked if there was a written schedule of activities staff 1 stated ?yes, but we don?t post that we only post the activity for that day?. 3. During the inspection on 1/16/2025, staff 1 provided a calendar labeled ?January 2025? with one activity listed each day, without an indication of the hour or length of activity.
Based on record review and staff interview, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR, was posted in the facility so that the information is readily available to all staff at all times. Evidence: 1. During the facility tour on 1/16/2025, there was no listing of staff with first aid or CPR posted. 2. During an interview with staff 1 on 1/16/2025, when asked where the first aid and CPR list was posted, staff 1 stated ?I didn?t know it needed to be posted.?
Based on record review and staff interview, the facility failed to ensure at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years. Evidence: 1.Upon request on 1/16/2025, the facility did not provide documentation of completed exercises in which the procedures for resident emergencies were practiced. 2. During an interview with staff 1 on 1/16/2025, when asked if there were any exercises for resident emergencies completed, staff 1 stated ?not that I can find?.
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: 10/15/2024 11:20am-12:50pm. 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 10/10/2024 regarding allegations in the area(s) of: Staffing and supervision. Number of residents present at the facility at the beginning of the inspection: 19 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: The Licensing Inspector observed residents during meals, staff answering call bells, and medication administration, the staff schedule and assignment sheets were also reviewed. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint 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. 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at jessica.gale@dss.virginia.gov
Based on direct observation and staff interview, the facility failed to ensure cleaning supplies and other hazardous materials in a locked area. Evidence: 1. During the facility tour on 10/15/2024, the licensing inspector observed the laundry room door next to the resident dining room cracked open with duct tape covering the latch, stopping the door from being secured. 2. The unsecured laundry room contained a shelf holding 2, gallon jugs of bleach, window cleaner, and various baskets of assorted cleaning supplies. 3. During an interview on 10/15/2024, staff 3 acknowledged the laundry room door was unlocked and stated, "we can't get into it if its locked". 4. Photo Evidence taken.
Based on direct observation the facility failed to ensure that the exterior of all buildings shall be maintained in good repair. Evidence: 1. Upon arrival to the facility during the inspection on 10/15/2024 at 11:20am a shutter on a window to the right of the front door on the front of the facility was falling off and hanging at the bottom. 2. Photo evidence taken.
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).
Based on resident record review and staff interview, it was determined that the facility failed to update an Individualized Service Plan ( ISP
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