VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Retreat at Berryville
450 Mosby Blvd.
Berryville, VA 22611
(540) 837-4447

Current Inspector: Jill James (540) 418-2631

Inspection Date: July 10, 2024 and July 11, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

Technical Assistance:

Reminder to submit renewal application at least 60 days prior to renewal.

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: 7/10/2024 9:15 a.m.- 3:15 and 7/11/2024 9:30- 1:00 p.m. 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: 62 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 Number of staff records reviewed: 3 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 3 Observations by licensing inspector: The Licensing Inspector observed staff engaged with the residents during activities, meal and medication administrations. Volunteers were on site for special activity. The following were reviewed at the time of inspection: Menus, activity calendars, fire drills, emergency drills, resident council minutes, dietician report, healthcare and medication oversight. Fire Marshall and VDH inspections. 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 hve any questions, please contact Jill James, Licensing Inspector at (540) 418-263 or by email at Jill.james@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-490-A
Description:	Based on record review and staff interview, the facility failed to ensure health care oversight was provided every six months. Evidence: 1.The facility record contained documentation of health care oversight dated 01/18/2023; 04/06/2023 and 04/10/2024. 2.Upon request Staff 5 did not provide any additional documentation to show a facility health care oversight had been completed six months after the date of 04/06/2023.
Plan of Correction:	Facility employed Licensed health care professional will perform on-site health care oversights at least every six (6) months, or more if indicated. Licensed health care professional will manually sign and date all entries and include the identification of the specific residents for whom the oversight was provided. Correction of violation anticipated by next oversight due 11/2024.
Standard #:	22VAC40-73-620-A
Description:	Based on facility records review and staff interview, the facility failed to ensure oversight at least every six months of special diets by a dietitian or nutritionist for each resident who has such a diet. Evidence: 1.The last dietary oversight was completed on 10/09/2023. 2.Staff 4 and 5 confirmed a dietary oversight had not been conducted every six months by a dietitian or nutritionist for all residents with a special diet.
Plan of Correction:	Virginia state recognized dietician visited on-site 08/01/2024 to complete oversight of special diets and review all residents nutrition. Dietician is contracted for scheduled on-site visits to occur at least every six (6) months. Correction of policy violation on 08/01/2024. .
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, the facility failed to ensure that Medication Administration Records (MARs) contained all required components to include the diagnosis. Evidence: 1. Resident 1?s July 2024 MAR did not have a diagnosis, condition, or specific indications for the medication Duloxetine 60 mg. (start date 6/20/2024) 1 tablet by mouth at bedtime. 2. Resident 2?s July 2024 MAR did not have a diagnosis, condition, or specific indications for the medication Melatonin 3 mg. (start 6/20/2024) 1 tablet by mouth at bedtime. 3. Resident 3?s July 2024 MAR did not have a diagnosis, condition, or specific indications for the medications Folic Acid 1 mg. (start date 6/20/2024) 1 tablet by mouth everyday and Rosuvastatin 20 mg. (start date 6/20/2024) 1 tablet by mouth at bedtime.
Plan of Correction:	All Medication Aides have been in-serviced and Pharmacy has been reminded to add diagnosis. Will continue training on making sure proper diagnosis are on medications before approving orders. Immediate correction of policy violation 07/15/2024.
Standard #:	22VAC40-73-950-E
Description:	Based on staff record review, staff interview and documentation reviews, the facility failed to ensure that a semi-annual review of the facility emergency preparedness plan was completed with all staff. Evidence: 1. Monthly training logs provided by Staff 5 document that emergency preparedness was reviewed on 03/29/2024 for 16 out of 45 staff and on 06/20/2024 for 12 out of 45 staff. 2. Staff 5 provided monthly staff meeting logs and confirmed there was not another way that emergency preparedness training was being tracked.
Plan of Correction:	Facility will provide emergency preparedness and response plan training to all staff during new hire and to all residents during move-in orientation. This training will extend to all volunteers and private duty aides. Facility will implement a plan to provide semi-annual emergency preparedness and response plan training to all staff and residents, including required individuals. To be documented in training binder and in associate file. All associates, residents, and required individuals not currently trained or documented trained are to be in-serviced by 09/30/2024 on emergency preparedness and response plan. Correction of policy violation on or by 09/30/2024.