VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Stratford House
1111 Main Street
Danville, VA 24541
(434) 799-2266

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Oct. 9, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

On 10/9/2019 one inspector conducted a complaint investigation (3:10pm to 5:05pm onsite - the investigation began with document review off-site) regarding improper discharge of a resident, physical plant issues, and a dispute between the residents family and the facility. There is no contract (written agreement) between the current licensee and the resident or legal representative, and the physical plant tour shows numerous repairs to the walls. One resident record was reviewed, numerous documents from the facility and complainant were reviewed, staff were interviewed. There is no evidence to support the complaint. The complaint is not valid. Two violations were noted during the investigation, and they are cited in the violation notice. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain the following: 1) steps to correct the noncompliance with the standard(s); 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions, please contact your licensing inspector at 540-309-3043.

Violations:

Standard #:	22VAC40-73-390-A
Complaint related:	No
Description:	Based on document review, the facility failed to have a written agreement with the resident or legal representative. EVIDENCE: 1. Resident 1 lived in the facility prior to the sale of the facility to the current owner. The only written agreement is with the prior owner, which is no longer valid.
Plan of Correction:	The identified resident has been discharged. An audit was completed to ensure all resident agreements are present in business files. Executive Director or designee will audit 5 resident business files per month to ensure on-going compliance.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on document review, the facility failed to address an assessed need on an updated individualized service plan (ISP). EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 1, dated 6/13/2019, shows this resident needs mechanical and human help with physical assistance to transfer. The ISP, dated 6/13/2019, does not address the type of mechanical help to be given.
Plan of Correction:	The identified resident has been discharged. All other UAIs were corrected to ensure compliance. UAI?s will be reflective of all identified needs of the resident to ensure the basic needs of the resident are adequately met. Executive Director will complete random monthly audit of a minimum of 5 residents to ensure ongoing compliance.