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 16, 2022 and May 18, 2022

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 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 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Technical Assistance:

1.Recommend new nurse attend the next phase 2 training provided by the licensing office ? administrator should attend for a review. 2.Facility had CPR and First Aid class scheduled for staff mid-June. 3.Monitor training hours especially as it relates to dementia and mental health ? online training can typically be adjusted to include those required trainings at the beginning of hire. Two Inspectors

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/16/2022 The Acknowledgement of Inspection form was signed and left at the facility for the initial date of the inspection. The second part was completed by phone with the nurse and the administrator. Number of residents present at the facility at the beginning of the inspection: 60 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 plus additional medication administration records Number of staff records reviewed: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Postings were as required and additional outside inspections had been completed and responded to as applicable. Meals were served as per menu and a medication pass was observed without issue. Additional Comments/Discussion: Fire Inspection -3/14/22 Health Inspection -3/8/22 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. Should you have any questions, please contact Sharon DeBoever, Licensing Inspector at (540) 292-5930 or by email at sharon.deboever@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-B
Description:	Based on a review of six resident records the comprehensive service plans were either missing or incomplete. Residents A and C comprehensive service plan which is required within thirty days of admission. Resident E had no seven-day or comprehensive as required. Resident D had no documentation of a six month review required following admission to a secure unit. The information contained on the uniform assessment instruments for the six files reviewed did not consistently match the information provided on the service plans that were available. They further did not consistently include mechanical supports required by the individual, special texture diets, oxygen when required, descriptions of behaviors and interventions. Service plans were observed not to be readily available to direct care staff. This was confirmed by interviews with 3 staff.
Plan of Correction:	As per the administrator, all records will be reviewed and brought into compliance. The administrator assumes responsibility for overseeing correction and future compliance. The facility will receive assistance as needed from applicable corporate staff. Service plans will further be made available to all staff. An in-service will be conducted and documented regarding service plans and the role direct care staff can play in regards to assessments and plans for individuals residing in the facility.
Standard #:	22VAC40-73-680-H
Description:	Based on a review of medication administration records (MARs) the MARs did not contain the required information including documentation from staff as required by the standard. Residents with physician orders for monitoring weight and the use of as needed medication did not include parameters when physician should be notified. Duplicate orders were on the MARs for resident E. For resident I staff were documenting removal of ankle supports on the same days staff had indicated application of the supports was refused. It was not clear which residents were and were not receiving wound care with the exception of resident C whose wound care was documented as being provided by medication aides which is out of their scope of practice.
Plan of Correction:	The facility nurse assumes responsibility along with the administrator for correction and future compliance of this standard. Physician orders will be reviewed, parameters added as applicable, duplicates removed. Medication aides are aware that wound care is out of their scope of practice ? the MAR will indicate this is to be done only by a nurse. All MARs will be reviewed, corrected and continued to be reviewed a minimum of monthly. The facility will receive assistance as needed from applicable corporate staff. They will further assist in monitoring.