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: Feb. 19, 2020 and Feb. 20, 2020

Complaint Related: Yes

Areas Reviewed:

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 BUILDING AND GROUNDS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-90 Background Checks for Assisted Living Facilities

Technical Assistance:

1. Please check service plans to ensure they include all the components as required by the standards. 2. An order for sliding scale insulin is viewed the same way as scheduled order is and does not require additional notes like a PRN unless resident refuses or it cannot be given, If the blood glucose level does not meet parameters for administration a "0" under units given will suffice.

Comments:

This inspection was conducted in response to a multiple complaints received by the licensing office. Complaints related to staffing, wound care and having staff with CPR training were not valid. Those related to medication administration. communication, incident reporting and care monitoring were found to be valid. There was also an incident in which CPR was started on an individual with a DNR order identified. The information was correct in the record. It was considered staff error in the moment and not facility and was clarified by the time emergency services arrived. Details can be found in the violation portion of this report. Thank you to residents,families, staff and outside providers for your assistance and cooperation in completing this complaint inspection process. Should you have additional questions or concerns please call (540) 332-2330 or e-mail this inspector at sharon.deboever@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-70-D
Complaint related:	Yes
Description:	An amendment was not sent to the licensing office in regards to an incident report involving resident D. Additional information was provided to licensing which had also been provided to the reporter. The information was verified but never included in an amendment from the reporting agency.
Plan of Correction:	ED & WD educated that additional information received after initial incident report sent, will require an amended incident report to be sent to VDSS.In addition, a progress note will need to be created regarding amendment. ED to review the state reports monthly to ensure reports that require additional information received after initial incident report sent, amended incident report has been sent to VDSS and progress notes and physicians have been updated. Initiated and ongoing
Standard #:	22VAC40-73-300-B
Complaint related:	Yes
Description:	This inspector acknowledges that the facility has a policy and procedures for both progress notes and daily communication log which share a great deal of information. In reviewing those it does not appear that the facility is consistently following their own policy resulting in not meeting the intent of the communication standard which to keep direct care on all shifts informed. This encompasses anything related to the physical and mental condition of residents. (Coordination and communication with outside services has also been included as opposed to writing a separate violation several communication issues are related.) Resident A There is a note that resident received a shower on 1/4/20 with the next note indicating any contact is dated 1/7/20. Resident B: Progress notes dated for 10/18 and 10/19 vary depending upon the entry. First entry for 10/18 notes hospice came in for toe - it was initially created at 2:53 pm on 10/19 and modified at 6:32 am on 10/20. Late entry dated 11/01 indicates hospice came 10/19 but but initial entry says 10/18. Initial pain complaint was noted for 10/18. Resident C: Daily log indicates morphine was given for pain on the evening of 2/10 but there is no corresponding dosage given on MAR. Review of the notes also appears to indicate there was not a lot of communication between staff and hospice related to wound care until 1/13 although hospice notes indicate they had been treating wounds. Resident D: Hospice notes indicate on 2/10 that a large amount of dried stool was in the brief and around the wound but there appears no communication with staff for additional attention. Resident H: Record notes indicate an ulcer consult 1/27/20 with no additional notes for follow up; staff notes resident complaining of pain in left side times five days with no additional information or follow up.
Plan of Correction:	WD & ED to conduct Inservice with RCA?s and Medtechs to review functioning of YARDI to include the following: Daily Log and Incident reporting Policy; Progress Note Policy; Process for entering the following: Daily Log, Progress Notes; Incidents Reports, Skin check forms during all showers and Messaging Abilities. WD & ED will conduct training on Carestream which allows for proper documentation of resident ADL Care. WD will implement that following Tracking/Verifications: Carestream ?Run daily reports to review the completion of resident daily ADL documentation Daily Log/Progress Notes ? review at daily stand-up and all ?concerns? will be followed up with a Progress note from WD. WD & ED will review daily log during stand up and sign off to acknowledge that they have read it. ED will monitor Carestream and Daily Log/Progress notes weekly to ensure compliance. Regional Director of Operations/ Corporate Clinical Support Specialist will be completing an audit quarterly to ensure that the documentation completed for compliance. Initiated and ongoing.
Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	Based on a random sample of individualized service plans the following was identified: Resident D: Plan notes "frequent" checks with no clarification. Resident E: The assessment tool (UAI) says behaviors are appropriate but the medication administration record indicates multiple medications for behaviors at least 3 times daily plus as needed medication and the service plans states occasional behaviors; service plan states requires assistance with meals but doesn't mention snacks.plans states staff to conduct routine rounds 3x per week; no mention of inability to use call bell but there is a statement to reposition every two hours; hospice in noted on plan with no description of services; individual receives depakote and having levels checked was not noted as part of the plan. Resident F: UAI states slight disorientation but service plans states needs assistance with being confused - needs clarification;wound care is noted on plan as once a week but showers are noted twice a week with no indication what is done with wound during that time. Resident G: Service plans notes self administration of medication but assistance with pain medication - needs clarification; daughter does bathing as per plan - needs documentation of training by facility; training provided to staff/family as it relates to assisting with prosthesis is not clear. Resident H: The service plan was updated 1/8/20 but the UAI was dated 7/13/19 and did not reflect what was in the service plan. Resident I: Service plan indicates resident is an elopement risk when resident is physically non-ambulatory; does not identify inability to use call bell and only says frequent checks; service plan was completed 12/2/19 and the UAI 12/10/19 so service needs don't match example being one says some disorientation and the other notes a higher level of disorientation.
Plan of Correction:	A 100% Audit has been completed in this area to ensure items corrected in this area. WD & ED to review ALL care plans to review the following: Accurate between UAI & Wording in Care plan; All instances of ?frequent checks? will be reviewed and time frames detailed; Ability to use call bell will be included on residents who CAN use the system as well as those who are not able. ED will review ALL care plans prior to them being finalized and reviewed with families. Regional Director of Operations/Corporate Clinical Support Specialist will conduct random monthly audit of Care Plan for results in compliance and recorded in file. Initiated and ongoing.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on review of the medication administration records medication was not administered as per physician orders or based on the standards of practice as outlined in the Board of Nursing medication aide curriculum - this violation incorporates issues related to administration, documentation and physician orders. Resident C: Order for diflucan to be given i tablet times three days - after first two doses documentation indicates on 2/7 "unable to retain" and "medication not her and and on 2/8 "medication not here"; humalog and blood glucose levels noted as "unable to physically take"; morphine .25 had a stop date of 2/10/20 and was given on 2/12/20; morphine on 2/13 at 11:08am given for pain and noted not effective - an additional note says blue ridge hospice ordered a single dose at 11:35am but documentation was timed at 2:25pm. Resident D: multiple refusals of medication with no indication physician notified but consistently wanted pain medication which was often noted as "helped some" or :some relief" with no follow up; 1/28 resident refused other medications but requested pain pill and specifically requested it not be crushed - there is no indication on the MAR that there is an order to crush resident's medication. Resident E: Has two medications to be given for a diagnosis of restlessness (haldol and seroquel) with no inidcation which is to be given first. Resident I: two orders for as needed/PRN ativan ,.5mg and 1mg with no distinction which is to be used; two medications for pain which states use acetaminophen first and call hospice if not effective after six hours but morphine may be used after four hours resulting in potentially 4 to 6 hours of pain if not effective. Resident J: Crestor order says give once daily with two administration times;Toujeo hold parameters were left off when order changed; ketononazole cream is to be applied to "affected areas" with no indication where they are; 2/10 and 2/11 cough and anxiety medications administered both noted to be ineffective with no additional notes regarding response by staff. Resident K: Blood glucose levels are ordered for three times daily with five times noted; on 2/3 and 2/4 blood glucose levels were 229,251 and 228 with no indication five units were administered as per sliding scale. Need to add a time frame to "if symptoms persist". Resident L:Oxygen needs source and amlopidine needs hold parameters. Resident M: Acetaminophen is specifically ordered for headache and noted given for leg pain; location of pain is often not identified and several instances of not being effective were noted with no documented follow up. Resident N: Weekly weights refused 2/12 and 2/18 with no indication and alternative day was tried; 2/1 order for ibuprofen 200mg/2 tablets at 11am with note that states "med not in cart only the pm one family had some on her so her daughter gave her some and on 2/15 note states "med given to POA to administer" with no indication why. Resident O: order to approximate skin flaps, apply neosporin as needed until healed with no point of reference. Resident P: Haldol PRN doesn't include parameters for how closely it can be given to scheduled dose. Resident Q: Naproxen is prescribed as needed/PRN for severe pain twice daily but notes to take with meals - needs clarification. Resident R: Novolog to be given on sliding scale - 2/1 and 2/3 at 5pm no documentation one unit was given and same is true for noon on 2/3 and 2/4. 2/3 and 2/11 only indicate with held per sliding scale with no blood glucaose documented.
Plan of Correction:	A 100% Audit has been completed in this area to ensure that all these items were corrected and that no other noncompliance. Wellness Director (WD) and Executive Director (ED) will conduct a training with ALL MedTechs on the following topics: Documentation of PRN: Effective vs. Non-Effective Communicate necessary to MD if PRN medication is NOT effective and proper documentation in Daily Log. Change of Shift Protocols ? Appropriate NARC Count, Review of PRN medications given & Review of any missed medication. Monthly Med Tech Observation with all MedTechs to be completed by WD, ED and Nurse. This will be documented and maintained in binder. Weekly Med-Exception and PRN Report to be completed by WD. This will be documented and maintained in binder. All exceptions will have progress note to be written. All orders will be reviewed by the WD, ED and/or Lead MedTechs prior to being approved and listed on MAR. The pharmacy will audit the facility med carts quarterly with their report focusing on physical inspection of the med carts, medications variance and random medication pass observations. ED to review the Weekly Med-Exception and PRN reports monthly. ED will also conduct monthly review of all resident with PRN medications, BG checks, insulin and BP. Regional Director of Operations/Corporate Clinical Support Specialist will conduct random monthly audit of MARS and Med Exception/PRN report. Date below indicates initiation and process will be ongoing.
Standard #:	22VAC40-73-930-D
Complaint related:	Yes
Description:	Based on interviews with administrative and care staff as well as service plan review, there was no documentation of rounds as required for individuals unable to use a call bell system. The service plans did not consistently describe how often checks were made and there were no "resident check forms' as outlined in the facilities own policies nor were there any additional documents to indicate time individual was checked on and initials of staff for each individual. This information was also not consistently reflected in the daily log.
Plan of Correction:	2-hr check binder was created in each neighborhood (Pearl & AL) on 2/20/2020 with a list of all residents who are on 2-hour checks, whether for positioning or safety.100% Audit of all care plans to ensure the requirement is reflected. Staff in-services conducted. ED to do random wellness chart audits quarterly to ensure service plans include resident?s ability to utilize the signaling device (pendant) or residents that require 2-hour checks are consistently addressed and accurate. Initiated and ongoing