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: Jan. 14, 2021 and March 23, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Recommend revisiting housekeeping policy with families when staff outwardly identify issues that cannot be addressed and room cleanliness maintained with schedule as provided as a part of the initial services. A cleaning checklist for housekeeping may be beneficial to include under bed and chairs, general bedding and furniture coverings, window sills, closets and monitoring plates and cups in rooms, especially in memory care.

Comments:

This complaint inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. The use of the remote protocol resulted in a longer period of time to bring the complaint to resolution. A complaint was filed with the licensing office indicating the facility failed to provide appropriate incontinence supplies. A second issue was failure to provide necessary health related information regarding special diet alternatives when an individual was having difficulty with the prescribed diet to families. An additional complaint was received at the same time regarding failure to follow the facility's own policy as it relates to falls. There were additional concerns raised regarding housekeeping issues which could not be pursued due to inspectors not being allowed in the facilities at this time. The first three allegations were found to be valid and are addressed in the violation portion of this report. The latter is noted in technical assistance. Three violations were identified. Based on the risk rating they will continue to be monitored as well as the recommendation in technical assistance. Should you have additional questions or concerns please call (540)332-2330 or email this inspector at sharon.deboever@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-40-A
Complaint related:	No
Description:	The facility failed to follow it's own policy in regards to the procedure to follow when someone falls and staff are aware that the individual hit their head as it relates to Resident A. The facility did not call 911 but instead let the family refuse service before the policy was implemented. It was noted and confirmed that the physician was also notified of the incident and the resident's and family refusal for transport.
Plan of Correction:	All staff were in-serviced as to the PSL Fall Policy. All staff were educated that when a resident has a fall and there is either confirmed or suspected head injury, that they are to call 911 immediately, and the resident/POA/family can then discuss with emergency services if they want to have transport assist. Staff were educated that residents and/or POA do have the right to refuse being transported to ER, but this refusal must be given directly to EMT while at the community. Residents and POA?s were also provided this information.
Standard #:	22VAC40-73-460-H
Complaint related:	No
Description:	The facility does not maintain an adequate stock of the correct size incontinence products as evidenced by a resident arriving at the hospital from the facility with a paper bed pad taped on them instead of wearing incontinence brief. The facility inventories their products once a month which would appear not to be sufficient.
Plan of Correction:	Resident Care Director and/or Wellness Director will be responsible to checking incontinence supply quantity twice a month, and order accordingly. Staff will be in-serviced as to where to locate the list of residents on incontinent program and understand the differences between those and residents on hospice. Additionally, staff will be educated on the difference levels of the incontinence program. These will be posted in the appropriate closets and updated upon changes.
Standard #:	22VAC40-73-470-A
Complaint related:	Yes
Description:	A review of notes for resident B indicate that the facility did not ensure either directly or indirectly, that the health care service needs of the resident was met. Documentation indicates a choking incident on whole food on 8/17/2020. The resident was noted to have a fair appetite but often fell asleep at the table while eating. Staff further notes that the resident is always coughing as if she is choking when eating on 10/01/2020. Resident continued to receive whole foods. A note on 10/2/2020 from a physician tele-med appointment states the physician would like to just monitor and see how she does. An additional note was added on 10/9/2020, after the resident again choked on food, stating a diet change was discussed with family during the 10/2/2020 appointment. The discussion was verified by the family but the various alternatives such as chopped or ground as opposed to moving from solid to pureed which was their perception of special diets was not reviewed with the family. The decision to maintain the diet may have been the same but the clarification of alternatives failed to be provided.
Plan of Correction:	Community will provide written descriptions of the following diets upon moving into the community and have signed for acknowledgement; Regular, Mechanical Soft and Pureed. Community will also provide education and documentation to existing POAs and Residents as to these differences. At any time, should the facility recommend a resident?s diet be downgraded, the POA will be educated as to the difference of diets, provide a written description, and signature of acknowledgement obtained. Facility will also request an order from MD for consult from speech therapist at this time.