Inspection Reports for Birch Ridge Senior Living
54 Imperial Dr, Staunton, VA 24401, United States, VA, 24401
Back to Facility Profile
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 3
Sep 16, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-09-15 regarding staffing and supervision and resident care and related services at the facility.
Findings
The investigation supported the complaint of non-compliance, including a failure to ensure at least two direct care staff members were awake and on duty at all times. Additional deficiencies were found related to failure to update the Uniform Assessment Instrument annually and failure to review and update individualized service plans at least once every 12 months.
Complaint Details
The complaint was substantiated. It involved an incident where a resident fell and was left on the floor for over 20 minutes without staff present, confirmed by EMS responders who found staff asleep during their shifts.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure there were at least two direct care staff members awake and on duty at all times. |
| Facility failed to ensure the Uniform Assessment Instrument (UAI) was updated annually. |
| Facility failed to ensure individualized service plans (ISP) were reviewed and updated at least once every 12 months. |
Report Facts
Number of residents present: 20
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of resident interviews conducted: 1
Number of staff interviews conducted: 2
Inspection Report
Monitoring
Census: 20
Deficiencies: 1
Aug 29, 2025
Visit Reason
The inspection was a monitoring visit to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found that the facility was operated by an acting administrator for more than 90 days, which is a violation. A permanent administrator was put in place immediately.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that it was not operated by an acting administrator for more than 90 days. |
Report Facts
Days acting administrator operated: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Licensing Inspector | Conducted the inspection and reviewed employee files and incident reports. |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 8
Jun 25, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-06-12 regarding allegations related to Resident Discharge, Building and Grounds, Resident Care and Related Services, Incident Reporting, and fall prevention.
Findings
The investigation found some substantiated violations including failure to report major incidents timely, incomplete annual reassessments, failure to update individualized service plans, inadequate supervision leading to multiple falls, failure to notify next of kin after falls, and poor maintenance and cleanliness of the facility interior and exterior.
Complaint Details
The complaint investigation was substantiated in part, with violations found in areas including resident discharge, building and grounds, resident care, incident reporting, and fall prevention.
Deficiencies (8)
| Description |
|---|
| Facility failed to report major incidents to the regional licensing office within 24 hours. |
| Annual reassessment using the Uniform Assessment Instrument (UAI) was not completed to determine if resident needs could continue to be met. |
| Individualized service plans (ISP) were not reviewed and updated at least annually or as needed for significant changes. |
| Facility failed to provide adequate supervision to prevent falls; resident had 19 falls with no interventions implemented. |
| Facility failed to notify next of kin or legal representatives after resident falls. |
| Outdoor area accessible to residents was not equipped with seasonally appropriate furniture; rocking chairs had ripped cushions and a rotting table was present. |
| Facility interior and exterior were not maintained in good repair and cleanliness; broken flowerpot, missing siding, broken recliner, feces in bathroom, soiled brief, and strong urine odor observed. |
| Facility failed to ensure the facility was free from foul odors. |
Report Facts
Number of residents present: 21
Number of resident falls: 19
Number of incident reports with no family notification: 10
Number of interviews with staff: 4
Number of resident records reviewed: 1
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 1
Jun 10, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-04-17 regarding allegations in the areas of Resident Care and Related Services, activities, meals, call bell response time, and building and grounds.
Findings
The investigation did not substantiate the complaint allegations of non-compliance. However, a non-complaint related violation was identified regarding the failure to store cleaning supplies and hazardous materials in a locked area.
Complaint Details
Complaint was not substantiated based on the evidence gathered during the investigation.
Deficiencies (1)
| Description |
|---|
| Facility failed to store cleaning supplies and other hazardous materials in a locked area. |
Report Facts
Number of residents present: 22
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
Number of cleaning supply containers observed: 19
Days to submit plan of correction: 5
Days to request review: 15
Days for public posting: 5
Inspection Report
Renewal
Census: 18
Deficiencies: 19
Jan 16, 2025
Visit Reason
The inspection was a renewal inspection conducted on January 16 and 17, 2025, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations related to staff training, documentation, emergency preparedness, resident care plans, and safety procedures. The facility was found non-compliant in areas including staff training timelines, tuberculosis risk assessments, posting of CPR/first aid certifications, individualized service plans, emergency drills, and fire safety measures.
Deficiencies (19)
| Description |
|---|
| Failed to ensure direct care staff training commenced no later than 60 days after employment. |
| Failed to ensure each staff person submitted tuberculosis risk assessment results prior to work. |
| Failed to post a listing of staff with current certification in first aid or CPR. |
| Failed to ensure direct care staff were trained in methods of dealing with residents with aggressive behavior prior to care involvement. |
| Failed to include names, job classifications, and charge person indication on written work schedule. |
| Failed to post the name of the current on-site person in charge in a conspicuous place. |
| Failed to include all identified needs on preliminary Individualized Service Plan (ISP). |
| Failed to ensure ISP was signed and dated by licensee, administrator, or resident/legal representative. |
| Failed to ensure at least 14 hours of scheduled activities weekly for residents. |
| Failed to post current month's written schedule of activities in a conspicuous location. |
| Failed to ensure a current picture of each resident was readily available for identification. |
| Failed to keep a current diet manual readily available to personnel responsible for food preparation. |
| Failed to include Do Not Resuscitate (DNR) orders in individualized service plans. |
| Failed to store cleaning supplies and hazardous materials in a locked area. |
| Failed to include inability to use signaling device in resident's individualized service plan. |
| Failed to develop and implement orientation and semi-annual review on emergency preparedness and response plan for all staff, residents, and volunteers. |
| Failed to ensure emergency fire and evacuation drawing contained all required information. |
| Failed to ensure fire and emergency evacuation drill frequency and participation in accordance with Virginia Statewide Fire Prevention Code. |
| Failed to ensure all staff participate in emergency procedure exercises at least once every six months with documentation maintained. |
Report Facts
Number of residents present: 18
Number of resident records reviewed: 2
Number of staff records reviewed: 3
Number of resident interviews conducted: 2
Number of staff interviews conducted: 3
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 2
Oct 15, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-10-10 regarding allegations in the area of staffing and supervision.
Findings
The investigation did not support the allegation of non-compliance with standards or law related to the complaint. However, two violations unrelated to the complaint were identified: unsecured hazardous materials in the laundry room and exterior building maintenance issues.
Complaint Details
The complaint was related to staffing and supervision but was not substantiated by the investigation.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure cleaning supplies and other hazardous materials were stored in a locked area; the laundry room door was taped shut but not secured. |
| The facility failed to ensure the exterior of all buildings was maintained in good repair; a shutter on a window was hanging off the front of the facility. |
Report Facts
Number of residents present: 19
Number of resident interviews: 2
Number of staff interviews: 3
Inspection Report
Renewal
Census: 21
Deficiencies: 1
Feb 16, 2024
Visit Reason
The inspection was a renewal inspection conducted to review compliance with licensing standards and regulations for the assisted living facility.
Findings
The facility was found to have a deficiency related to failure to update an Individualized Service Plan (ISP) annually as required, based on resident record review and staff interview.
Deficiencies (1)
| Description |
|---|
| Facility failed to update an Individualized Service Plan (ISP) annually as required. |
Report Facts
Records reviewed: 6
Interviews conducted: 7
Inspection Report
Complaint Investigation
Deficiencies: 3
Aug 28, 2023
Visit Reason
The inspection was conducted due to a complaint and a self-report received by the VDSS Division of Licensing regarding allegations of failure to provide medication as prescribed and failure to have oversight by a qualified person.
Findings
Violations were identified related to the complaints and self-report, including failure to name a qualified administrator during absence and medication administration issues such as late medication delivery and missed medication due to agency staff issues.
Complaint Details
The complaint was substantiated with all three aspects found to be valid, including failure to provide medication as prescribed and failure to have oversight by a qualified person.
Deficiencies (3)
| Description |
|---|
| The facility failed to name an otherwise qualified person to be the administrator during the absence of the newly named administrator. |
| On 8/12/23 morning medication for all residents was administered outside the one hour after parameter due to lack of a medication aide and refusal of previous shift aide to stay. |
| On 8/27/23 morning medication was not given to any residents due to agency staff not being able to log into the computer system and agency directing medication aide not to administer medication. |
Report Facts
Inspection date range: Inspection conducted from 8/15/23 to 8/28/23
Medication administration time: 9.25
Medication administration time parameter: 1
Days delay for administrator arrival: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Inspector | Named as current inspector conducting the inspection |
| Sharon DeBoever | Licensing Inspector | Contact person for questions regarding the inspection |
| Vice president of operations | Mentioned in relation to administration assistance and medication administration issues |
Inspection Report
Monitoring
Census: 26
Deficiencies: 0
Mar 16, 2023
Visit Reason
A monitoring inspection was conducted as a follow-up to the renewal inspection to review compliance and staff criminal record reports since the last inspection.
Findings
The inspection found no violations with applicable standards or laws. The inspector conducted a tour of the facility, reviewed staff records, and observed meals and activities.
Report Facts
Number of resident records reviewed: 0
Number of staff records reviewed: 5
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 4
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 0
Jan 30, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-01-18 regarding allegations in the area of Administrative and Administrative Services.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. Observations included a tour of the facility and infection control practices, along with interviews of residents and staff.
Complaint Details
Complaint related to Administrative and Administrative Services; the allegation was not substantiated.
Report Facts
Number of residents present: 27
Number of resident interviews: 3
Number of staff interviews: 4
Inspection Report
Renewal
Census: 27
Deficiencies: 10
Jan 30, 2023
Visit Reason
The inspection was a renewal inspection conducted on January 30 and 31, 2023, to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple areas of non-compliance including incomplete criminal record reports, delayed tuberculosis testing, incomplete first aid training, outdated FA/CPR posted list, insufficient activities, inadequate meal planning and dietary oversight, medication management deficiencies, and lack of emergency food supply.
Deficiencies (10)
| Description |
|---|
| Failed to ensure one of fourteen staff had a criminal record report completed within 30 days of hire. |
| Failed to ensure one of five tuberculin skin tests was completed within seven days of hire. |
| Failed to ensure one of five staff completed first aid training within 60 days of hire. |
| Failed to ensure the first aid and CPR posted list was kept current. |
| Failed to ensure at least 14 hours of activities were held each week with no less than one hour each day. |
| Failed to ensure a written schedule of activities was posted. |
| Failed to ensure meals met the USDA food guidance system. |
| Failed to ensure dietary oversight was completed every six months. |
| Failed to implement the facility medication management plan by not ensuring medications were ordered and available to avoid missed doses for two resident medication administration records reviewed. |
| Failed to ensure at least a 96-hour supply of emergency food was available with 48 hours being on site. |
Report Facts
Number of residents present: 27
Number of resident records reviewed: 6
Number of staff records reviewed: 6
Number of resident interviews: 3
Number of staff interviews: 6
Medication administration records reviewed: 2
Hours of activities required weekly: 14
Days for CRR completion: 30
Days for TB test completion: 7
Days for first aid training completion: 60
Hours of emergency food supply required: 96
Hours of emergency food supply on site: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Named in findings related to incomplete first aid training and medication administration | |
| Staff 5 | Named in findings related to delayed criminal record report, tuberculosis testing, and first aid/CPR certification | |
| Staff 7 | Interviewed regarding emergency food supply availability | |
| Administrator | Interviewed and responsible for corrective actions and compliance |
Inspection Report
Monitoring
Deficiencies: 2
Jun 27, 2022
Visit Reason
The inspection was a monitoring visit to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found non-compliance with applicable standards, including failure to report a stage 2 wound to the licensing office and failure to document all medications administered to a resident on the medication administration record.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure a stage 2 wound was reported to the licensing office. |
| Facility failed to ensure all medications administered to one resident were documented on the medication administration record. |
Report Facts
Number of resident records reviewed: 9
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 4
Admission date of Resident 4: Jun 14, 2022
Physician's orders date for Resident 4: Jun 9, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Licensing Inspector | Current inspector conducting the inspection. |
| Janice Knight | Licensing Inspector | Contact person for questions about the inspection. |
Inspection Report
Monitoring
Census: 24
Deficiencies: 9
May 9, 2022
Visit Reason
The inspection was a monitoring visit conducted on May 9 and May 10, 2022, to review compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations including incomplete staff work schedules, missing resident orientation documentation, incomplete individualized service plans, lack of a pharmacy reference book, missing diagnoses on medication orders, failure to administer treatments as ordered, hot water temperature exceeding limits, incomplete fire drill records, and insufficient resident emergency procedure training for staff.
Deficiencies (9)
| Description |
|---|
| Facility failed to maintain a work schedule that included all substitutions and changes. |
| Four of six resident records lacked signed documentation that resident orientation was completed. |
| Four of six individualized service plans did not include all assessed needs and services provided. |
| Facility failed to ensure at least one pharmacy reference book was readily accessible. |
| One of two residents' physicians' orders reviewed did not include a diagnosis for each medication. |
| One of two residents' treatments were not administered as ordered due to missing medication. |
| Hot water temperature in bathroom sink exceeded the required maximum of 120 degrees Fahrenheit. |
| Fire drills were not conducted each shift in a quarter as required. |
| Resident emergency procedures were not reviewed with all staff at least once every six months. |
Report Facts
Number of residents present: 24
Number of resident records reviewed: 6
Number of staff records reviewed: 5
Number of medication administration observations: 17
Hot water temperature: 124.9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Licensing Inspector | Conducted the inspection and interviews, and documented findings. |
| Janice Knight | Licensing Inspector | Contact person for questions regarding the inspection. |
| Wency Chapnkem | Interim Administrator | Identified noncompliance in resident emergency procedure training and provided training on February 17, 2022. |
| Acting Administrator | Administrator in Training | Involved in corrective actions and interviews related to multiple deficiencies. |
| Regional Director of Nursing | Director of Nursing | Involved in corrective actions and monitoring of compliance. |
Inspection Report
Monitoring
Deficiencies: 0
Mar 14, 2022
Visit Reason
An unannounced monitoring inspection was conducted to follow up on previous violations related to staff training.
Findings
Based upon documentation and staff interviews, there were no violations found during this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 18, 2022
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to a complaint received on 2022-02-16 alleging exploitation and neglect.
Findings
The investigation included interviews with residents and staff and found that the information did not support the allegations. The complaint was determined to be not valid and no violations were found.
Complaint Details
Complaint was related to allegations of exploitation and neglect. The complaint was determined to be not valid with no violations resulting from the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 31, 2022
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to a complaint received on 2021-12-28 regarding staff conduct and broken equipment.
Findings
The investigation included interviews with residents and staff and found that the information did not support the allegations. The complaint was determined to be not valid and no violations were found.
Complaint Details
Complaint was received on 2021-12-28 alleging staff conduct and broken equipment. The complaint was investigated and determined to be not valid with no violations.
Inspection Report
Complaint Investigation
Deficiencies: 4
Jan 31, 2022
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to a complaint received on 2022-01-10 regarding allegations of insufficient resident care and staff not having the required training.
Findings
The investigation substantiated the complaint that staff did not have the required training, including orientation, direct care aide training, first aid certification, and CPR certification. However, the allegation of insufficient resident care was not supported.
Complaint Details
The complaint was substantiated regarding staff not having the required training but was not substantiated regarding insufficient resident care.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure 13 of 18 staff completed or had documentation of orientation within the first seven working days of employment. |
| Facility failed to ensure one of 18 staff had documentation of completion of direct care aide training within 60 days of hire. |
| Facility failed to ensure nine of 18 staff had current first aid certification. |
| Facility failed to ensure at least one staff person on duty had current certification in cardiopulmonary resuscitation (CPR). |
Report Facts
Staff without orientation documentation: 13
Staff records reviewed: 18
Staff without direct care aide training documentation: 1
Staff without first aid certification: 9
Staff without CPR certification: 13
First aid training scheduled date: Feb 8, 2022
Inspection Report
Monitoring
Deficiencies: 0
Nov 1, 2021
Visit Reason
A non-mandated monitoring inspection was initiated due to a follow-up on a medication administration violation from a previous self-reported investigation.
Findings
The virtual inspection conducted on November 1 and 3, 2021, found no violations with applicable standards or law from the previous inspection. No violations were issued.
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 22, 2021
Visit Reason
A self-report was received regarding allegations in the area of resident care and related services, prompting a non-mandated self-report inspection initiated on 9/22/2021 and concluded on 9/23/2021 to investigate medication administration practices.
Findings
The investigation found that the facility failed to ensure one of two residents' medications were administered as ordered by the physician and according to medication aide standards, resulting in a violation.
Complaint Details
The visit was complaint-related based on a self-report regarding medication administration errors. The evidence supported the self-report of non-compliance, and a violation was issued.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure one of two residents' medications were administered as ordered by the physician and in accordance with medication aide standards. |
Report Facts
Inspection dates: 2
Medication error date: Sep 4, 2021
Medication refresher training deadline: Oct 18, 2021
Observation duration: 60
Performance assessment duration: 120
Inspection Report
Renewal
Census: 16
Deficiencies: 4
Feb 11, 2021
Visit Reason
A renewal inspection was initiated on 2/11/21 and concluded on 2/17/21 to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations including failure to ensure timely first aid certification for staff, incomplete signed written assurances in resident records, failure to maintain current registration with the Virginia Department of State Police, and incomplete sex offender registry checks prior to resident admission.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure one of three staff completed first aid certification within the required timeframe. |
| Facility failed to ensure four of eight resident records reviewed had a signed written assurance on file. |
| Facility failed to ensure registration with the Virginia Department of State Police remained current to receive sex offender notifications. |
| Facility failed to ensure three of seven resident records reviewed had a sex offender registry check completed prior to admission. |
Report Facts
Inspection dates: 3
Staff first aid certification deficiency: 1
Resident records with unsigned written assurance: 4
Resident records missing sex offender registry check: 3
Current census: 16
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 6, 2020
Visit Reason
A complaint inspection was initiated on November 6, 2020, following a complaint received regarding an allegation in the area of resident care.
Findings
The investigation concluded on January 27, 2021, with evidence gathered not supporting the allegation of non-compliance with standards or law.
Complaint Details
A complaint was received by the department on 11/6/20 regarding an allegation in the area of resident care. The administrator was contacted by telephone to conduct the investigation. The evidence gathered did not support the allegation of non-compliance.
Loading inspection reports...
