VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Berryville
413 McClellan Street
Berryville, VA 22611
(540) 955-4557

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: May 5, 2021 and May 20, 2021

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 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 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 COMPLAINT INVESTIGATION.

Technical Assistance:

1. New administrator since the initiation of this inspection process. 2. Facility will be notified of the next training related to standards and regulations.

Comments:

This 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. A renewal inspection was initiated on 5/5/21 and concluded on 5/20/2021. The interim administrator was contacted by email to initiate the inspection. The current census was reported to be 46. The inspector emailed the interim administrator a list of items required to complete the inspection. The inspector reviewed four resident records plus three additional medication records, a billing record for one resident, three staff records plus background check information for nine staff hired since the last inspection, documentation related to fire and health inspections, health care over site, emergency drills, pharmacy review, dietary oversight, staff schedules and additional training records and certification for staff as applicable to their positions. Due to Covid the healthcare kitchen certificate was renewed without a formal inspection by the local Virginia Department of Health and is current. The fire inspection is forthcoming but was also delayed due to Covid and verified. The information gathered during the inspection determined two violations of applicable standards or law. Violations are noted in this report and were in the areas of medication administration and facility policy and procedure. Thank you to the staff and families for your assistance and cooperation during this remote inspection process. The facility will be notified by mail regarding their licensing status as determined by the risk assessment profile tool and review by the licensing administrator. Should there be additional questions or concerns please call (540)332-2330 or e-mail this inspector at sharon.deboever@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-390-A
Description:	Based on a review of billing statements, agreement information and the inability of the facility to produce documentation to the contrary, the facility failed to notify the family of Resident I of a level of care changed as outlined in their own policies and agreement which resulted in an increase in monthly fees. The family further was not included in the review process for the level of care change remotely of by phone.
Plan of Correction:	The Executive Director assumes responsibility for correction and future compliance. When there is a review for a level of care change families will be notified of the need for an updated assessment and inclusion in the development of a new plan. Should the change result in a fee increase the executive director or the resident care director will immediately notify the family and/or resident of the change. The Executive Director assumes responsibility for correction and future compliance.
Standard #:	22VAC40-73-680-D
Description:	Based on a review of medication administration records, medication was not administered as per physician orders or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.: Resident A: Proctozone - HC External cream was ordered 4/7/21 to be administered twice daily for 10 days. Medication was documented as administered through 4/28/21. Resident A further received ten doses throughout the month of April of acetaminophen four of which were noted to be "not effective" with no indication of what was done for follow up to assist the resident. The resident also has multiple as needed medications for pain with no indication to medication aides administering which should be used first. Resident B: Hydrocodone - Acetaminophen was ordered 4/20/21 to be administered daily at 9pm. Documentation indicates no medication was given 4/20- or 4/22 to 4/25 but was given 4/21/21. Resident D: Has two as needed medications both designated for pain with no indication for medication aides administering which should be used first. Resident E: There is no documentation to indicate the reason an as needed medication was administered on 4/10, 4/14 or 4/16. Resident F: There are multiple as needed medications for pain with no indication for medication aides which should be administered first. As it relates to those medications seven doses of hydrocodone were documented as administered with the reason given only documented for one and seven doses of acetaminophen were documented as given with the reason given documented for one.
Plan of Correction:	The Executive Director and Resident Care director will immediately begin to review medication administration records randomly for errors. The medication that was not administered was due to an issue with the pharmacy, but it is understood that the facility needs to have an alternate plan that includes notifying the physician that the medication is not available and document accordingly. Executive Director and Resident Care Director will conduct a training immediately with registered medication aides, letting them know that if they discover a medication is not available, they must let the Resident Care Director know immediately so that they are able to follow up. The Executive Director assumes responsibility for ensuring correction and future compliance via ongoing medication management audits and consistent training with the registered medication aides provided by the resident care director and executive director.