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: May 21, 2021 and June 21, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Facility has a renewal inspection due in July, 2021. The facility has a new administrator.

Comments:

A complaint was received and investigated via desk review and interviews by this licensing office related to medication administration and provision of personal care services. The complaint was found to be valid and details are noted in the violation portion of this report. Thank you to staff for your assistance with this complaint inspection. Should you have additional questions or concerns please call (540)332-2330 or email this inspector at sharon.deboever@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-460-B
Complaint related:	No
Description:	The service plan for Resident A, who resided in the assisted living portion of the building, indicates that assistance will be provided with wearing hearing aides and they would be kept in the medication cart at night. Documentation provided by the facility and family interviews reflects multiple occasions when the hearing aides were not available, located or the resident was not assisted with putting them in. Resident is also noted to be lactose intolerant but a meat and cheese sandwich was found in her room on several occasions.
Plan of Correction:	In-services pertaining to personal care to include and pertaining to medical devices will be starting immediately for all care staff. Working with kitchen to offer a wider variety of diets to be available in the Bistro. It should be noted that the Bistro is open to all residents in the assisted living portion of the building and they may make choices that are not appropriate to their diet regardless of what is available. Working with direct care staff on ISP?s and to be more aware of residents with refrigerators in their rooms and the contents. Educating direct care staff on proper documentation, follow up, and follow through, when diets are not being followed. Training will be mandatory and attendance documented. The administrator and director of nursing assume responsibility for correction and monitoring for future compliance.
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on a review of medication administration records for March and April for Resident A, medication was not administered in accordance with the physician's 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. 3/1 - Melatonin administered for pain when prescribed for insomnia Order written 3/5 for melatonin 3mg/3tablets at 7pm for insomnia - first dose given on 3/9 3/15 - MAR reflects all 7am medications were administered but resident had left facility mid-day on 3/14 through mid-day 3/20. 3/27-3/29 Colestipol (for hyperlipidemia) noted as not available from: 5 doses missed 3/29-4/1 Memantine (for dementia) not available: 7 doses missed Paperwork was originally signed 3/23/21 by family to ensure delivery from facility pharmacy but had to be resigned 4/1/21. 3/29 - PRN melatonin administered for restlessness but noted to be "not effective" with no additional follow up notes. 4/15 Scheduled melatonin noted as "not available".
Plan of Correction:	We will conduct in-services on eMAR software, pharmacy protocols, dietary, company policy and procedures, and personal care to include and pertaining to medical devices and these in services will be starting immediately. Med tech refreshers for proper medication administration protocols given by the VA Board of Nursing (scheduled June 29th for nearly all of our Med techs on that date and all of our med techs mandatory attendance by end of year) and utilizing other resources to assist with these in services. Working on more med cart audits to correct deficiencies and reinforce required med tech duties. Performance evaluations/Counseling to review the 6 Rights of Medication Administration and Med Tech protocols are being followed. Utilizing sister communities best practices that may work for them in these instances. The administrator and director of nursing assume responsibility for correction, monitoring and future compliance.