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: Jan. 23, 2024

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

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 8:30 am on 1/23/2024 and exited at 3:50 pm. 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: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based upon a review of records during a mandated monitoring inspection conducted on 1/23/2024, the facility failed to ensure that each direct care staff member who did not have a current certification in first aid, received certification in first aid within 60 days of employment for one out of five staff members. Evidence: 1. Staff 3 was hired on 10/24/2023 as a direct care staff. No first aid certification was found in the record for Staff 3.
Plan of Correction:	Staff 3 will complete CPR and First Aid on February 16, 2024. ED and RCD will periodically audit new associates records to ensure ongoing compliance.
Standard #:	22VAC40-73-680-D
Description:	Based upon a review of records, the facility failed to ensure that medications were administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. Resident 4 (R4) had an order from a physician for Gabapentin 300mg to be administered three times a day. 2. According to the Medication Administration Record (MAR) for R4, Gabapentin 300mg was administered on 1/9/2024 at approximately 8am, 2pm, and 8pm and on 1/15/2024 the medication was administered to RV at approximately 8 am, 2pm, and 8 pm. 3. According to the Controlled Drug Record for R4, the scheduled 2 pm Gabapentin was not administered on 1/9/2025 and 1/15/2024. 4. Resident 6 (R6) had an order from a physician for Gabapentin 100mg to be administered twice daily. 5. According to the MAR for R6, Gabapentin 100mg was administered to R6 at approximately 9am and 9pm on 1/4/2024, and on 1/14/2024 at approximately 9 am and 9 pm. 6. According to the Controlled Drug Record for R6, the 9pm scheduled Gabapentin 100mg was not administered on 1/4/2024 and 1/14/2024.
Plan of Correction:	Training of all medication aides was conducted immediately to ensure all medication given is documented appropriately in the Controlled Drug Record. The ED and RCD will periodically monitor MAR and Control drug records to ensure ongoing compliance.