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: Nov. 13, 2020 and Feb. 9, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

I suggest you review your training on dealing with agitated and aggressive residents (reg 270) to make sure it addresses behaviors and appropriate actions for such residents in memory care. It appears that the training program could be strengthened, giving staff more effective methods to deal with residents.

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 monitoring inspection was initiated on 11/13/2020 and concluded on 2/9/2021. A self-reported incident was received by the department regarding allegations in the area of resident rights. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the monitoring inspection but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-550-C
Description:	Based on interview and resident record review, the facility failed to provide a resident with resident rights as provided in Section 63.2-1808 of the Code of Virginia. EVIDENCE: 1. Resident 1 was not free of physical restraint and was not treated with dignity and respect. According to the written incident report submitted by the facility on 10/9/2020, the following occurred on 10/5/2020. (Names have been replaced with numbers for privacy.) "Resident 1 was in our dining room on the Memory Care unit. She was picking up items and she took a piece of food off of another resident's plate. A staff person was witnessed grabbing her arm and forcing the food from her hand. During the investigation, it was noted by reviewing cameras of the shift that staff 1 did grab the residents arm and pry food out of hand, staff 1 also grabbed her arm again to take another item out of her hand at a different time of the shift. It was also observed by video review that staff 2 observed some of this abusive behavior and did not intervene and also on one occasion grabbed/pushed the resident (1) inappropriately. Also observed on video, was staff 3 grabbing the resident/pushing/pulling. During interviews with these individuals it was reported by staff 3 and staff 1 that they were asked by staff 2 to help hold the resident to give her medication." 2. This information was confirmed in a phone interview with the staff 6, and by interview notes completed by staff 6, 7, , and 8 after interviewing staff 1 through 5.
Plan of Correction:	What Has Been Done to Correct? All current associates will review the Rights and Responsibilities of Assisted Living Facilities provided in Section 63.2-1808 of the Code of Virginia, which will be in addition to their initial upon hire and their annual review. All current community associates will receive a copy of the Indicators of Adult Abuse, Neglect or Exploitation. Each associate will read the indicators, along with the Acknowledgement of Mandated Reporter Status. After reviewing the documents each associate will sign the Acknowledgement of Mandated Reporter Status and the document will then be placed in the employee files. Associates will be trained on Commonwealth Senior Living Restraint Policy and Procedure ? Staff shall observe and respect the personal rights of a residents including being free from physical and chemical restraints. Program Assistant will assist with Dementia Training, will increase memory care programming, and assist the care team with behavioral interventions. How Will Recurrence Be Prevented? Focus on Aggressive Behavior, safe release, w/ roleplay, and a deep review of Residents Rights were implemented. Business Office Manager or designee will assign additional trainings to all community associates and ensure trainings are completed and documented. Person Responsible: Interim Executive Director, Resident Care Director, Assistant Resident Care Director, Program Director and Program Assistant