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:

Complaint Related: No

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.