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 2, 2023

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. Be consistent with alternative source for oxygen. 2. Website contains most current serious cognitive impairment and appropriateness of placement form (dss.virginia.gov)

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: 5/2/2023 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 59 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Since the last inspection several physical plant areas have been updated included closing in the front porches, new flooring in the dining area along with tables and chairs and office areas have been changed. Number of resident records reviewed: 12 Number of staff records reviewed: 7 plus background checks/sworn disclosures. Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Residents were busy with activities as scheduled, Postings were as per regulations. There is both a weekly and daily menu that includes alternatives for residents. Additional Comments/Discussion: Outside inspections were current as we related drills. Fire:4/6/23 Health:11/14/22 An exit meeting was 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 #:	22VAC40-73-1100-A
Description:	Based on the review of four resident records for individuals who reside in the memory care portion of the program, Resident D did not have documentation of approval for placement by the family, appropriateness for placement by the facility or serious cognitive impairment by a physician. Observation and interview with resident indicated that resident qualified to reside in memory care. The physical did also indicate a diagnosis of dementia.
Plan of Correction:	Resident D now has the completed approval for placement form, appropriateness of placement form, and serious cognitive impairment assessment added to their chart. The Resident Care Director will complete a chart audit to ensure that all residents residing in Memory Care have the appropriate placement paperwork in place.
Standard #:	22VAC40-73-1140-B
Description:	Six of the seven staff files reviewed did not have documentation of ten hours of dementia training within the first four months of hire. They receive and have documentation for five hours at the time of hire. The balance of training is intended to be provided through the Relias online program as per the administrator. Review of that information by this inspector did not produce the required ten hours of training.
Plan of Correction:	Commonwealth Senior Living currently provides all staff with a live 5 hour dementia training course within their first 60 days of hire. Moving forward the Executive Director and Resident Care Director will ensure that an additional 5 hours of dementia specific training is completed by all staff as assigned to them via our Relias online training portal within their first 4 month of hire.
Standard #:	22VAC40-73-260-A
Description:	Staff A, hired 1/12/23, and Staff B, hired 11/8/22, did not have documentation of having first aid and CPR within the first 60 days of hire or having had it since hire. There were other staff in the building certified in both as required.
Plan of Correction:	Staff A and B will have their CPR and First Aid completed on May 12th 2023. Moving forward, The Executive Director and Resident Care Director will ensure all new staff members obtain their CPR and First Aid certification within their first 60 days of hire.
Standard #:	22VAC40-73-450-B
Description:	Based on a review of a random selection of resident records facility staff did not include documented geri psych services residents were receiving on their respective individualized service plans. It was further observed that for the plans reviewed for individuals living on the memory care unit, the plan did not indicate the individual?s ability to use the call cord or staff response in the absence of that ability.
Plan of Correction:	The Executive Director and Resident Care Director will perform an audit of all resident?s care plans that are currently receiving geri psych services and will ensure the services are appropriately documented and updated as part of the residents care plan.
Standard #:	22VAC40-73-680-D
Description:	Based on a review of medication administration records: A.Hospice orders for prn medications do not consistently indicate what to do if symptoms persist. B.Resident I has an order for morphine that is to be used for pain if Tylenol is ineffective. Resident received morphine for pain on 30 different occasions when Tylenol was not tried first as per the physician order. On two occasions ibuprofen was given prior to the morphine. On 11 occasions either morphine, haloperidol or lorazepam was given and noted to be not effective with no indication if the facility nurse or hospice was notified for additional instructions to assist with decreasing continued symptoms. The order for sliding scale insulin indicates to notify physician is blood glucose is less than 450 and should read if greater than 450. Resident also has two orders by two different physicians to check blood glucose level twice daily with one stating before morning and evening meals but the MAR shows 9am and 9pm with the other order simply reading ?BID? and it?s scheduled for 7am and 4pm. C.Resident K has an order for compression sleeves to be put on at night and removed in the morning. Based on documentation K refused placement on 5/2,5,6,14,15, and 16. Staff on the morning shift, however, documented they removed the sleeve on 5/3,6,7,15,16, and 17. On May 3 there is a notation that K refused novolog from sliding scale ? blood glucose is noted to have been 92 which would not require novolog as per the scale.
Plan of Correction:	Executive Director and Resident Care Director will ensure that residents medications are administered in accordance with physician or other prescribers? instructions. Resident Care Director will conduct a mandatory training with all medication aides on Thursday, June 1st and will review specific topics such as following physician?s orders, PRN medication orders, and proper documentation as it relates to PRN medications and specific parameters. The facility medication management plan will be reviewed thoroughly with registered medication aides during this meeting, quarterly and as needed. If PRN medication is not effective, Registered Medication Aide will contact Resident Care Director or Assistant Resident Care Director, who will then notify the resident?s primary care physician for guidance on next steps. The Executive Director and Resident Care Director will ensure all PRN orders include the following per regulatory guidelines: a) symptoms indicating the use of medication b) exact dosage c) the exact time frames the medication is to be given in a 24 hour period d) directions as to what to do if symptoms persist and e) results of PRN medication and follow up if applicable. The Executive Director and Resident Care Director will perform bi monthly