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. 13, 2021 , Feb. 10, 2021 and Feb. 18, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

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 complaint investigation was initiated on 1/13/2021 and concluded on 2/18/2021. A complaint was received by the department regarding allegations in the areas of resident care and additional requirements for facilities that care for adults with serious cognitive impairments. 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 did not support the complaint of non-compliance with standards or law. Any violations not related to the complaint investigation but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-440-A
Complaint related:	Yes
Description:	Based on resident record review, the facility failed to update a uniform assessment instrument (UAI) when the condition of a resident had a significant change. EVIDENCE: 1. The UAI for resident 1 dated 5/1/2020 shows this resident has the behavior of wandering, passive. Notes in the resident record document violence toward staff and other residents on 8/15/2020,8/29/2020, 8/30/2020, 9/3/2020, 9/18/2020, 10/14/2020, and 12/23/2020. The incident on 8/29/2020 resulted in resident 2 having a hip fracture requiring surgery and rehabilitation. The UAI was not updated to show the violent behavior pattern.
Plan of Correction:	The Resident Care Director or designee reviewed the UAI for resident 1 on the date of the inspection. The UAI was updated to include the behavior patterns for resident 1. In the future, the Resident Care Director or designee will review and crosswalk the UAI once completed to ensure that every detail matches and ensure that every need is addressed comprehensively on each resident's ISP. The Resident Care Director or designee will be responsible for implementing and monitoring this plan.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on resident record reviews, the facility failed to update individualized service plans (ISP) after significant changes in resident's conditions. EVIDENCE: 1. The ISP dated 5/3/2020 for resident 1 does not address agitated or aggressive behavior that was documented in the resident record on 8/15/2020 through 12/23/2020.
Plan of Correction:	The Resident Care Director or Designee reviewed the ISP for resident 1 on the date of the inspection. The ISP was updated to include the agitated or aggressive behavior. In the future, the Resident Care Director or designee will review and crosswalk the ISP once completed to ensure that every detail matches and ensure that every need is addressed comprehensively on each resident's ISP. The Resident Care Director or designee will be responsible for implementing and monitoring this plan.