Inspection Reports for Birch Gardens

The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on 2025-07-08 regarding allegations in the area of Resident Care and Related Services.

The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The licensing inspector reviewed resident records, incident reports, and facility communication logs and found no issues.

The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-06-24 regarding allegations related to Building and Grounds at the facility.

The investigation supported some but not all of the allegations, identifying non-compliance in the areas of Building and Grounds. Violations were found related to unscreened operable windows, poor maintenance and cleanliness of the interior building including the kitchen, and furnishings not kept in good repair.

The complaint was related to Building and Grounds. The evidence gathered supported some of the allegations. A violation notice was issued. The licensee has the opportunity to submit a plan of correction.

The inspection was a monitoring visit conducted to assess compliance with applicable standards and laws, including a tour of the physical plant, review of resident and staff records, and observations of resident activities and care.

The inspection identified multiple violations including inadequate staff certification and staffing levels, failure to post the on-site person in charge, incomplete resident assessments, improper medication labeling, lack of physician orders for restraints, unsafe storage of hazardous materials, building maintenance issues, and deficiencies in emergency preparedness and recordkeeping.

A complaint was received by VDSS Division of Licensing on 5/14/2025 regarding allegations in the area(s) of Resident Care and Related Services, prompting a complaint inspection.

The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings were reviewed and no deficiencies were cited.

Complaint related to Resident Care and Related Services; the allegations were not substantiated based on the investigation.

The inspection was a monitoring visit conducted following a self-report received by VDSS Division of Licensing regarding allegations in the areas of personnel, resident care and related services, and protection of adults and reporting.

The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The licensing inspector observed staff and resident interactions, resident rooms, bathrooms, and common areas without identifying deficiencies.

The inspection was conducted in response to a complaint received on 2024-12-10 regarding allegations related to resident care and related services, staffing, and reporting at the facility.

The investigation supported the allegations of non-compliance with standards and laws, resulting in violations issued. Deficiencies included failure to update individualized service plans, inadequate supervision of residents including wandering behaviors, failure to notify next of kin or protective services after incidents, and failure to document residents' inability to use signaling devices.

The complaint was substantiated. It involved allegations of resident wandering, lack of supervision, failure to notify family or protective services after incidents, and inadequate individualized service plans.

The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 11/21/2024 regarding allegations related to building and grounds, resident care and related services, and medication administration.

The investigation supported some, but not all, of the allegations of non-compliance with standards 670, 680-D, and 870-A. Violations included failure to ensure staff administering medication were properly registered, failure to administer medications according to physician's orders, failure to maintain the building in good repair, and issues with hazardous materials storage and resident record security.

Complaint investigation was substantiated in part. Allegations included unlicensed medication administration, improper medication administration, building maintenance issues including mold, and unsafe storage of hazardous materials.

The inspection was conducted in response to a complaint received on 10/15/2024 regarding allegations of resident to resident physical abuse, incident reporting, and reporting suspected abuse.

The investigation supported some, but not all, of the allegations. The facility was found non-compliant with standards related to incident reporting, mandated reporting of suspected abuse, and communication among staff regarding resident incidents. A violation notice was issued with opportunities for the licensee to submit a plan of correction.

The complaint was substantiated in part, involving allegations of resident to resident physical abuse and failures in incident and abuse reporting.

The inspection was conducted in response to a complaint received on 2024-06-23 regarding allegations in the area of resident care at the assisted living facility.

The investigation supported some but not all allegations, identifying areas of non-compliance with several standards related to resident care and medication management. Violations included failure to report major incidents timely, failure to implement accurate medication management plans, and failure to document medication administration properly.

The complaint investigation was substantiated in part, with evidence supporting some allegations of non-compliance related to resident care and medication management.

The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on May 31, 2024, regarding allegations in the area of resident care.

The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection findings will be posted publicly within five business days.

Complaint related inspection triggered by allegations in resident care; the complaint was not substantiated.

The inspection was a monitoring visit conducted on April 22, 2024, following a self-reported incident received by VDSS on April 19, 2024, regarding allegations in Resident Care and Related Services.

The investigation did not support the self-report of non-compliance, but violations unrelated to the self-report were identified, including failure to report an incident timely, failure to communicate significant happenings to all shifts, and failure to update the Individualized Service Plan to reflect hospice admission.

The inspection was a renewal inspection conducted to review compliance with licensing standards and regulations for the assisted living facility.

The facility was found deficient for failing to have documentation of a coordinated plan of care on the Individualized Service Plan (ISP) between the facility and the Hospice agency for two residents.

This monitoring inspection was conducted as a follow-up to the previous renewal inspection.

The evidence gathered during the inspection determined no violations with applicable standard(s) or law.

The inspection was conducted in response to a complaint received by VDSS Division of Licensing on January 24, 2023, regarding allegations in the area of Administration and Administrative Services.

The investigation did not support the allegation of non-compliance with standards or law. The licensing inspector completed a tour of the facility and conducted interviews with residents and staff. An assessment for mold was recommended and scheduled for February 2023.

Complaint related to Administration and Administrative Services; evidence gathered did not support the allegation of non-compliance.

The inspection was conducted in response to a complaint received on 2023-01-03 regarding allegations related to Resident Care and Related Services and Buildings and Grounds at the facility.

The investigation supported some of the allegations, identifying non-compliance in activities and housekeeping. Violations were found related to failure to ensure weekly deep cleaning of resident rooms and failure to provide at least one hour of daily activities totaling 14 hours per week.

The complaint was substantiated in part, with evidence supporting non-compliance in activities and housekeeping standards.

The inspection was a renewal inspection conducted on January 23 and 24, 2023, to assess compliance with applicable standards and regulations for the assisted living facility.

The inspection identified multiple areas of non-compliance including incomplete hospice agreements, outdated individualized service plans (ISPs), failure to meet USDA meal guidelines, lack of timely dietary oversight, medication administration and documentation errors, missing oxygen orders and signage, and incomplete fire drill documentation.

The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 10/6/2022 regarding allegations in the areas of resident accommodations and buildings and grounds.

The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant including the building and grounds and conducted interviews with residents and staff.

Complaint related inspection with allegations concerning resident accommodations and buildings and grounds; the complaint was not substantiated.

The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing on 2022-09-19 regarding allegations in the areas of Personnel and Resident Care and Related Services.

The investigation supported the self-report of non-compliance with standards or law, resulting in violations issued related to medication management and storage. The facility failed to ensure the medication management plan was implemented and failed to store a scheduled II medication in a double locked area.

The inspection was conducted in response to a complaint received by the Virginia Department of Social Services Division of Licensing on 2022-07-27 regarding allegations in the area of resident care and related services.

The investigation supported some, but not all, of the allegations. Areas of non-compliance were found related to resident care, medication administration documentation, and medication administration. A violation notice was issued with opportunities for the licensee to submit a plan of correction.

The complaint was substantiated in part, with evidence supporting non-compliance in resident care and medication administration areas.

The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at the assisted living facility.

The inspection found non-compliance related to medication administration records (MARs) documentation for three residents. The facility failed to ensure all required documentation was included on the MARs, as evidenced by missing entries and initials.

An unannounced monitoring inspection was conducted to review compliance with regulations including general provisions, administration, personnel, resident care, emergency preparedness, and other requirements for assisted living facilities.

The facility was generally clean and compliant with postings, menus, and activities; however, areas of noncompliance were identified including outdated first aid and CPR certification postings, incomplete staff schedules, deficiencies in individualized service plans, medication administration errors, unlabeled over-the-counter medications, incomplete medication reviews, unsecured cleaning supplies, and incomplete fire drills.

A non-mandated complaint inspection was initiated on 11/16/2021 following a complaint received regarding allegations in administration, administrative services, and resident care.

The investigation found no evidence supporting non-compliance with staff failing to obtain medical care for a resident, but did support the allegation that a family member was not notified of an incident. Additionally, the facility failed to report five major incidents to the licensing office within 24 hours.

Complaint related to allegations in administration and resident care; substantiated for failure to notify family of an incident but not substantiated for failure to obtain medical care.

A renewal inspection was initiated on 2/1/21 and concluded on 2/4/21 to assess compliance with applicable standards and laws at the assisted living facility.

The inspection identified non-compliance related to criminal record checks, specifically two of twelve checks were not completed within 30 days of hire. Violations were documented and a plan of correction was issued to ensure future compliance.