VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Retreat at Berryville
450 Mosby Blvd.
Berryville, VA 22611
(540) 837-4447

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: July 2, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

1. Make sure Do Not Resitate/DNR is consistently on plans; 2.Any medication given for a behaviors should have an intervention outlined on the service plan; 3. Review of upcoming trainings in August, 2019; and 4. In order for town hall meetings to be counted as training the topic needs to be noted on the training form with back up materials available.

Comments:

The information contained in this renewal inspection report will be reviewed by the licensing administrator. the facility will be notified by mail regarding their renewal status. Two violations were identified during this unnanounced renewal inspection. They were in the area of CPR/first aid postings and medication orders and documentation. Details can be found in the violation portion of this report. Previous violations identified during inspections due to the facility having a conditional license had been corrected. Resident and staff records were reviewed. Other postings were as required. Outside inspections were current as were related drills. Follow-up had been completed from pharmacy and dietary reviews. The facility was clean and odor free. Lunch appeared to meet physician orders and was as noted on the menu. Residents interviewed voiced no concerns. There have been no complaints received during this six month conditional period. Thank you to residents,staff and families for your cooperation during this inspection process. Should you have additional questions or concerns please call (540) 332-2330 or e-mail this inspector at sharon.debeover@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-260-C
Description:	The facility listing of staff currently certified in first aid or CPR was not posted in the secure unit. It was posted in assisted living but not readily available to those in the secure unit.
Plan of Correction:	A list will immediately be placed in the secure unit readily available to all staff and families in that area. Lists will be updated as needed. The administrator assumes responsibility for monitoring future compliance.
Standard #:	22VAC40-73-680-K
Description:	Based on a reviewed of a random sample of medication administration records as it relates to as needed/PRN medications, what to do if symptoms persist was not consistently indicated nor was what the person administering medication did when the medication was not effective.
Plan of Correction:	All staff will be reinserviced on proper documentation and notifications is regards to the use of as needed medication. Orders will also be reviewed to ensure that all have indications for what to do if symptoms persist or related parameters. The director of nursing assumes responsibility for correction. The administrator and director of nursing assume responsibility for future compliance.