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: June 26, 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:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 6/23/2020 and concluded on 6/26/2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 47. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, staff schedules, staff training for resident rights and elopement prevention, fire and health inspections, and background checks on new staff people submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-450-D
Description:	Based on resident record review, the facility failed to show what services hospice will provide to a resident on the individualized service plan (ISP). EVIDENCE: 1. The ISP for resident 3 shows that hospice care is provided, but it does not specify what hospice is doing, nor how often.
Plan of Correction:	Resident # 3 ISP was updated on 06/25/2020 to ensure resident?s ISP reflects hospice services to include what hospice does and how often they visit. ED and/or designee will audit current hospice services residents ISP?s to ensure hospices services have been identified. ED and/or designee will conduct monthly ISP audits on at least 5 resident ISPs per month. Monitoring will be on-going
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review, the facility failed to have a complete order for oxygen for a resident. EVIDENCE: 1. The order for resident 2 lacks information regarding the delivery device and the source.
Plan of Correction:	MD notified to reflect Resident #2 source for oxygen delivery. Will have an order with delivery source by 06/29/2020. ED and/or designee will audit current residents who receive oxygen orders to ensure source of delivery is identified. RCD will review all new Oxygen Orders for regulatory compliance. ED and/or designee will conduct monthly audits of resident?s receiving oxygen for source of delivery and regulatory compliance. Monitoring will be on-going.