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: Jan. 21, 2020

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 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.

Comments:

On 1/21/2020 three inspectors conducted a monitoring visit. 39 residents were in care. Nine resident records were fully reviewed and five staff records were fully reviewed. In addition, other resident records were partially reviewed and all new staff records were reviewed for background check compliance. Staff and residents were interviewed, medication passes were observed, a meal was observed, and a physical plant tour was done. During the inspection and at the exit interview, the facility was given the opportunity to discuss the violations and to show that they were in compliance. 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 #:	22VAC40-73-220-B
Description:	Based on document review and interview, the facility failed to meet requirements for private duty personnel. EVIDENCE: 1. Two private sitter files were reviewed and neither one indicated if they were from an agency or a direct hire from the resident or family. Staff at the facility stated that private sitters 1 and 2 were hired by resident family members, and not through an agency. Management staff at the facility said they find out when new sitters start by looking at visitor logs to see if anyone has started. The files for sitters 1 and 2 lacked clear descriptions of their duties. 2. The TB screening for sitter 1 was done most recently on 2/28/1018, over a year ago. 3. The services sitter 2 is supposed to provide for resident 1 are not clearly shown on the individualized service plan (ISP). The section that shows a need for a private sitter states, "work together with sitter to provide best care possible for resident 1." 4. The services sitter 1 is supposed to provide for resident 7 are not shown on the ISP. The private sitter is not addressed at all on the ISP, dated 4/8/2019.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-250-C
Description:	Based on record review, the facility failed to ensure that verification of a current job description was maintained in staff record. EVIDENCE: 1. The record for staff 3 did not contain verification of a current job description for the employee.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that staff obtain and maintain current First Aid certification. EVIDENCE: 1. The records for staff 1 and 2 did not indicate current First Aid certification. 2. The records for staff 4 and 5 did not indicate that new staff received First Aid certification within 60 days of employment.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-A
Description:	Based on review of resident record, the facility failed to ensure that the physical examination contained all required components. EVIDENCE: 1. Resident 2 was admitted to the facility on 11/21/2019. The ?RESIDENT PHYSICAL EXAMINATION REPORT? for resident 2 does not contain the following: date of exam, height/weight, description of the resident?s reactions to allergies, and a statement that specifies whether the resident is or is not capable of self-administering medication. 2. Resident 11 was admitted to the facility on 11/17/2019. The ?RESIDENT PHYSICAL EXAMINATION REPORT? for resident 11 does not contain the following: blood pressure, description of the resident?s reactions to allergies, and a statement that specifies whether the resident is or is not capable of self-administering medication. 3. The pre-admission physical for resident 12 lacked a list of medications
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-B
Description:	Based on review of resident record, the facility failed to ensure that the annual risk assessment for tuberculosis (TB) was completed. EVIDENCE: 1. The ?REPORT OF TB SCREENING? for resident 6 lacked results of the PPD administered on 06/16/2019 and contact information for the ?MD/designee or Health Department Official?. .
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-325-B
Description:	Based on review of resident record, the facility failed to ensure that a fall risk rating was reviewed and updated at least annually. EVIDENCE: 1. Resident 6 ?MORSE FALL SCALE? was last completed on 10/13/2018. 2. The record for resident 7 did not have a fall risk rating for the resident, who moved in 4/30/2018.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-410-A
Description:	Based on review of resident record, the facility failed to ensure upon admission the resident and their legal representative were provided an orientation including emergency response procedures, mealtimes, and use of the call system. EVIDENCE: 1. The business record for resident 11 contained a blank copy of the facility?s orientation with no signatures or dates.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review, the facility failed to have a uniform assessment instrument (UAI) completed in accordance with Assessment in Assisted Living Facilities (22VAC30-110). EVIDENCE: 1. The UAI for resident 12, dated 8/23/2019 and 9/9/2019 shows the resident is disoriented to some spheres all of the time; however, they are not identified. The assessor has not signed or dated the UAI.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-A
Description:	Based on review of resident records, the facility failed to ensure the preliminary plan of care was signed and dated by the licensee, administrator, or his designee (i.e., the person who developed the plan), and by the resident or his legal representative. EVIDENCE: 1. The ?PRELIMINARY INDIVIDUALIZED SERVICE PLAN? for resident 5 and resident 11 did not identify who the plan was completed by and did not contain a resident/POA signature.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to address a resident need on a comprenehsive individualized service plan (ISP). EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 12 shows this resident is abusive/aggressive/disruptive weekly or more with behaviors of "hits at staff, wanders in other residents rooms, and aggressive. The ISP shows the service given for this need is to monitor for the reduction of or elimination of triggers.... and does not identify what the triggers are.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-E
Description:	Based on review of resident records, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. EVIDENCE: 1. Resident 5 was admitted to the facility on 07/23/2019. The comprehensive ISP in the resident?s record was not signed or dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. 2. Resident 11 was admitted to the facility on 11/17/2019. The comprehensive ISP for resident 11 was not signed/dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative until 01/10/2020. 3. The comprehensive ISP dated 07/18/2019 for resident 6 was not signed by the resident or the resident?s legal representative.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to update the uniform assessment instrument (ISP) when a resident's condition changed. EVIDENCE: 1. On 11/19/2019 resident 1 was prescribed a special diet. This need has not been addressed on the ISP dated 12/18/2019. 2. Pm 1/14/2020 resident 7 was prescribed a special diet. This need has not been addressed on the ISP, dated 4/8/2019.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-560-E
Description:	Based on tour of the physical plant, the facility failed to ensure that the resident?s records were kept in a locked area. EVIDENCE: 1. The medication cart on the third floor contained a paper medication administration record (MAR) for resident 13 underneath the glass covering of the top of the medication cart. During time of observation, no staff were present at the medication cart and the resident?s information was accessible. 2. The nursing area desk in the memory care unit had a paper MAR for resident 14 left out on the desk, where it was visible to anyone walking past the desk.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-650-A
Description:	Based on observation and document review, the facility held a medication from a resident without an order to hold it. EVIDENCE: 1. Resident 1 was scheduled to have Biotene mouthwash at approximately 11:3A0AM, and the medication aide said it was being held, so it was not given. The file for resident 1 did not have an order to hold the Biotene mouthwash.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-660-A-3
Description:	Based on observation and interview, the facility failed to ensure that an individual responsible for medication administration kept the keys to the medication storage area on his person. EVIDENCE: 1. At approximately 12:25PM staff 1 picked up an apron from a counter in the nurse's desk area, and removed the medication cart keys from the pocket. She stated she kept the keys in the pocket of the apron, but was not allowed to wear the apron in the dining room. Staff 1 did not have control of the keys while she was in the dining room of the memory care unit.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-660-A-7
Description:	Based on observation, the facility failed to ensure that dedicated medical supplies and equipment shall be appropriately labeled. EVIDENCE: 1. The glucometer for resident 10, which was stored on the medication cart, was not labeled with resident?s name.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-I
Description:	Based on observation, the facility failed to ensure that the medication administration record (MAR) contained the diagnosis, condition, or specific indications for administering drugs or supplements. EVIDENCE: 1. The January 2020 MAR for resident 6 did not include the following for Austedo 9MG: date prescribed; diagnosis, condition, or specific indications for administering the drug and route. 2. The MARs for residents 2, 3, 4, 9, and 10 did not contain the diagnosis, condition, or specific indications for administering drugs or supplements for certain listed medications.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-720-A
Description:	Based on record review, the facility failed to ensure that the written Do Not Resuscitate Order (DNR) was included in the individualized service plan (ISP). EVIDENCE: 1. The ISP, dated 10/15/2019, for resident 10 indicated that the resident is a full code; however, the record for the resident contained documentation of a DNR order, dated 01/16/2020.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-860-G
Description:	Based on tour of the physical plant, the facility failed to ensure that hot water taps available to residents shall be maintained within a range of 105 degrees Fahrenheit to 120 degrees Fahrenheit (F). EVIDENCE: 1. The hot water taps in the following residents? rooms did not reach a temperature of 105F to 120F: room 214 registered at 136.3F, room 220 registered at 137F, room 306 registered at 92.1F and room 202 registered at 100.4F.
Plan of Correction:	Not available online. Contact Inspector for more information.