1 Inspection Summary
Inspection Reports Summary
Covers 25 inspections · Feb 2021 – Feb 2026Visit Reason
This report covers 25 inspections of Birch Gardens by the Virginia Department of Social Services from February 1, 2021 to February 25, 2026, including routine, complaint, monitoring, and renewal inspections.
Complaint Details
There were 13 complaint visits. Complaints included allegations of resident care, building and grounds issues, medication administration, staffing, reporting suspected abuse, and resident wandering. Investigations supported some but not all allegations, resulting in violations issued and plans of correction.
Findings
Across that history VDSS cited 80 violations under 47 distinct standards. 18 of 25 visits ended with violations cited and 7 with none. 13 inspections were prompted by a complaint.
Violations (69)
22VAC40-73-870-A: Facility failed to maintain interior of building in good repair with gaps in flooring and missing cabinet doors.
22VAC40-73-680-G: Over-the-counter medications were not labeled with resident's name.
22VAC40-73-450-C: ISP did not include written description of services to address identified needs such as bed rails.
22VAC40-73-260-A: Staff failed to complete first aid certification within 60 days of hire.
22VAC40-73-350-B: Registered sex offender search not completed prior to admission.
22VAC40-73-320-A: Physical examination not obtained within 30 days preceding admission.
22VAC40-73-640-A: Medication management plan failed to prevent use of expired medications.
22VAC40-73-950-E: Semiannual review of emergency preparedness plan not completed twice a year for all staff, residents, and volunteers.
22VAC40-73-680-D: Medications not administered according to physician's instructions (wrong eye for eye drops).
22VAC40-73-990-C: Staff failed to participate in emergency procedure exercises at least once every six months.
22VAC40-73-870-D: Facility failed to keep building free of insect infestations (gnats).
22VAC40-73-870-A: Facility interior not maintained in good repair with gaps in flooring posing tripping hazards.
22VAC40-73-870-E: Furnishings not kept clean and in good repair; carpets soiled with body fluids and feces present.
22VAC40-73-870-B: Facility failed to ensure building was free from foul, stale, and musty odors including urine and feces smells.
22VAC40-73-860-D: Operable windows were not effectively screened.
22VAC40-73-870-A: Interior of building not maintained in good repair and kept clean; kitchen had dried food and missing cabinet parts.
22VAC40-73-870-E: Furnishings not kept in good repair; broken rocking chairs on front porch.
22VAC40-73-680-G: Over-the-counter medications not labeled with resident's name or in pharmacy-issued container until administered.
22VAC40-73-990-C: Staff failed to participate in emergency procedure exercises at least once every six months.
22VAC40-73-950-E: Failed to implement orientation and semi-annual review of emergency preparedness plan for all staff, residents, and volunteers.
22VAC40-73-280-A: Staffing plan not followed; insufficient staff scheduled for shifts to meet residents' needs.
22VAC40-73-710-C: Restraint used without physician's written order specifying conditions and duration.
22VAC40-73-870-A: Interior and exterior of buildings not maintained in good repair; gaps in flooring posing tripping hazards.
22VAC40-73-710-D: Failed to assist resident with restraint at least every 10 minutes for hydration, safety, comfort, and other needs.
22VAC40-73-970-E: Fire and emergency evacuation drill records not kept for two years; missing records for July 2024 and May 2025.
63.2-1720-C-2: Criminal history record reports not obtained on or prior to 30th day of employment for five employees.
22VAC40-73-450-C: ISP failed to include all assessment needs identified on Uniform Assessment Instrument (UAI).
22VAC40-73-260-A: Direct care staff failed to receive first aid certification within 60 days of employment.
22VAC40-73-290-B: Staff schedule did not post names of current on-site persons in charge.
22VAC40-73-350-B: Failed to ascertain prior to admission whether potential resident was a registered sex offender.
22VAC40-73-860-I: Cleaning supplies and hazardous materials not stored in locked area.
22VAC40-73-450-F: ISP not reviewed and updated at least once every 12 months or as needed for significant change.
22VAC40-73-460-D: Failed to provide supervision to prevent resident wandering and notify appropriate parties after elopement.
22VAC40-73-930-D: ISP did not include inability to use signaling device for resident.
22VAC40-73-460-F: Failed to notify next of kin, legal representative, or responsible agency of resident fall or wandering incident.
22VAC40-73-560-E: Resident records not stored in locked area; medication room door propped open.
22VAC40-73-260-C: Listing of staff with current first aid or CPR certification not kept up to date.
22VAC40-73-870-A: Interior of building not maintained in good repair; mold and rotting baseboards observed.
22VAC40-73-860-I: Hazardous materials not stored in locked area; medication room and other doors left open.
22VAC40-73-260-A: Staff failed to receive first aid certification within 60 days of employment.
22VAC40-73-670-2: Staff administering medication not registered with Virginia Board of Nursing as medication aide.
22VAC40-73-680-D: Medications not administered according to physician's instructions.
22VAC40-73-130-A: Failed to report suspected abuse, neglect, or exploitation as mandated reporters.
22VAC40-73-70-A: Failed to report major incidents to licensing office within 24 hours.
22VAC40-73-300-B: Failed to utilize written communication to inform all shifts of significant happenings or problems.
22VAC40-73-450-H: Resident rooms not deep cleaned weekly as stated in individualized service plans.
22VAC40-73-520-E: Failed to ensure at least one hour of activities daily with total of 14 hours weekly.
22VAC40-73-700-1: Oxygen orders incomplete and no 'No Smoking - Oxygen in Use' signs posted at resident rooms.
22VAC40-73-610-C: Meals did not meet USDA food guidance system requirements for fruit and vegetable servings.
22VAC40-73-620-A: Dietary oversight not completed every six months.
22VAC40-73-970-E: Fire drills not documented as required; missing evacuation time and weather information.
22VAC40-73-680-I: Medications administered not documented on medication administration record for one resident.
22VAC40-73-310-M: Hospice agreements did not include required information about coordinated plan of care.
22VAC40-73-680-E: Treatment not provided as ordered for one resident.
22VAC40-73-450-F: Individualized service plans not updated to include all assessed needs for multiple residents.
22VAC40-73-680-D: Medications administered not according to physician's orders; wrong doses and times.
22VAC40-73-680-I: Medication administration record missing documentation of PRN medications administered.
22VAC40-73-450-H: Care and services specified in individualized service plans not provided to resident.
22VAC40-73-660-A-2: Scheduled II medication not stored in double locked area.
22VAC40-73-640-A: Medication management plan not implemented properly; narcotic counts incomplete.
22VAC40-73-680-G: Over-the-counter medications not labeled with resident's name.
22VAC40-73-450-F: Individualized service plans failed to include all assessed needs of residents.
22VAC40-73-650-B: Physicians' orders lacked diagnosis for medications.
22VAC40-73-290-A: Staff schedule did not indicate who was in charge at any given time.
22VAC40-73-690-B: Medication reviews not conducted at least once every six months.
22VAC40-73-870-I: Cleaning supplies left unlocked and unattended.
22VAC40-73-680-G: Over-the-counter medications not labeled with resident's name.
22VAC40-73-460-F: Failed to notify required individuals when resident fell.
22VAC40-73-70-A: Failed to report five major incidents to licensing office within 24 hours.
Report Facts
Violations cited: 80
Distinct standards: 47
Inspections on page: 25
Inspections with violations: 18
Complaint visits: 13
Loading inspection reports...
