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: May 13, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 inspection was initiated on 5/13/2021 and concluded on 5/17/2021. A complaint was received by the department regarding allegations in the area of resident care and related services. 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(s)/self-report) of non-compliance with standards or law, and violations were issued. Any violations not related to the (complaint(s)/self-report) but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-460-A
Complaint related:	No
Description:	Based on resident record review, the facility failed to assume general responsibility for the health, safety, and well-being of a resident. EVIDENCE: 1. An electronic record labeled All Vitals showed that on 1/20/2021 the resident's pulse was 1332 beats per minute heart rate. 2. There is no documentation to support that the physician or rescue squad was contacted because of the abnormal BPM heart rate, and no documentation to show that this entry was corrected, if it needed correction.
Plan of Correction:	What has been done to correct? Weekly review of vital entries will be conducted. Corrections will be made as applicable. Instructions for MD notification will be implemented. Training will take place at staff meeting on 5/27/21. Person Responsible: Resident Care Director, Assistant Resident Care Director or designee
Standard #:	22VAC40-73-580-F
Complaint related:	Yes
Description:	Based on resident record review, the facility failed to implement interventions when a nutritional problem was suspected. The interventions include: weighing residents at least monthly to determine whether the resident has significant weight loss (i.e., 5.0% weight loss in one month, 7.5% in three months, or 10% in six months); and notifying the physician if a significant weight loss is identified in any resident wo is not on a physician-approved weight reduction program and obtaining, documenting, and following the physician's instructions regarding nutritional care. EVIDENCE: 1. Resident 1 moved into the facility on 01/13/2021. 2. A copy of the pre-admission physical shows on 01/05/2021 resident 1 weighed 163 pounds. 3. A physician office visit note from the resident record shows that on 01/05/2021 resident 1 weighed 163 pounds. 4. The Weight and Vital Sign Record shows the following: a.) Admission weight 161.3 pounds; b.) 01/14/2021 weight 161.3 pounds crossed out and rewritten as 146.9 pounds by staff 2; and c.) 02/02/2021 weight 147.2 pounds. 5. The 14.1 pound difference between admission weight and weight on 02/02/2021 shows a weight loss of over 7.5% in 20 days.. 6. The Progress Notes lack any documentation of physician contact regarding the 14.1 pound weight loss between 01/13/2021 and 02/02/2021, a 20 day period. 7. The Progress Notes show that starting 02/10/2021 resident 1 began refusing to eat.
Plan of Correction:	What has been done to correct? Residents will be weighed at the beginning of each month and weight analysis report will be reviewed monthly and will be recorded electronically. PCP will be notified via Weight Variance Physician Notification form if applicable. Person Responsible: Resident Care Director, Assistant Resident Care Director or designee.
Standard #:	22VAC40-73-650-A
Complaint related:	No
Description:	Based on resident record review and email, the facility failed to obtain a valid order from a physician prior to administering a medication. EVIDENCE: 1. The January 2012 and February 2012 medication administration records (MAR) show that quetiapine fumarate (Seroquel) 25 mg was administered to resident 1 on the following dates and times: 250mg, 8 PM beginning 01/30/2021 through 02/03/2021, and at 8AM and 8PM beginning 02/09/2021 through 02/22/2021 at 8AM. 2. The resident record has no signed order for this medication, and this was confirmed by an email from staff 1.
Plan of Correction:	What has been done to correct? Audit of all orders to ensure that they have the required PCP?s signature. Person Responsible: Resident Care Director, Assistant Resident Care Director or designee.
Standard #:	22VAC40-73-650-C
Complaint related:	No
Description:	Based on resident record review and interview, an oral medication order not signed within 14 days. EVIDENCE: 1. The record contained a copy of a telephone order from the physician's office to the pharmacy dated 02/04/2021. The order discontinued quetiapine 25 mg PO HS, and started Seroquel (quetiapine fumarate) 25mg twice a day, hold if sedated. It has not been signed by the physician.
Plan of Correction:	What has been done to correct? All new phone orders into the pharmacy are to be reviewed to ensure physician signature within 14 days. Person Responsible: RCD, ARCD or designee
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on resident record review and interview, the facility failed administer a medication in accordance with the physician's order. EVIDENCE: 1. The January and February medication records (MAR) show that quetiapine fumarate 25 mg was administered to resident 1 at 8AM and 8PM beginning 02/09/2021 through 02/21/2021 and on 02/22/2021 at 8AM. 2. The unsigned oral order sent from the physician to the pharmacy for resident 1 shows to administer Seroquel [quetiapine fumarate] 25 mg, take one tab PO BID [twice a day], hold if sedated. 3. January and February MARs showed that registered medication aides (staff 2 through 5) administered the medication to resident 1. Registered medication aides are not qualified to determine if a resident is sedated or not. They are not licensed health professionals. 4. The January and February 2021 MARs show the following medications were not administered as ordered: 01/18/2021 and 01/22/2021 8AM dose of Lubricant Eye Drops - didn't see in cart; 01/25/2021 8AM dose of metoprolol Tartrate 25 mg - medication will be ordered, 01/17/2021 and 01/18/2021 8AM dose of Tamsulosin HCI 0.4 MG - not in cart, 01/24/2021 8AM dose of Omeprazole 20 mg - ordered, 01/17/2021 8AM dose of Atorvastatin 20 mg - medication not in the building, 01/18/2021 8AM dose of Atorvastatin 20 mg - not in cart, 01/23/2021 8PM dose of DOK 100 mg - not available, 01/24/2021 8PM dose of DOK 100 mg - ordered, 02/09/2021 8AM dose of Tension Headache Oral Tablet 500-65 mg - ordered from pharmacy, and 02/09/2021 8AM dose of Quetiapine Fumarate 25 mg - ordered from pharmacy.
Plan of Correction:	What has been done to correct? A complete order audit is being completed for MD Clarification on this type of order to ensure that Med Aids are not asked to determine if a resident is sedated since they are not licensed for such determinations. Daily order administration tracking will be completed. The report will be presented to Medication Aids for corrections when indicated. A new order refill roster is being implemented and training for staff will take place in staff meeting on 5/27/21. Person Responsible: Resident Care Director, Assistant Resident Care Director and/or designee
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on resident record review, the facility failed to have some required items on the medication administration records (MAR). EVIDENCE: 1. The January 2021 MAR for resident 1 is lacking diagnosis, condition, or specific indications for administration of the drug or supplements listed below: Atorvastatin Calcium oral tablet 20 MG, Bupropion HCI oral tablet 100 MG, Lubricant Eye Drops Ophthalmic Solution 0.4-0.3%, Quetiapine Fumarate Oral Tablet 25 MG, Tamsulosin HCI Oral Capsule 0.4 MG, Tension Headache Oral Tablet 500-65 MG, Vitamin B-12 tab 1000 TR, Alka-Seltzer Original #36 (PRN), Antacid Calcium Tablet Chewable 500 MG (PRN), Deep Sea Nasal Spray Nasal Solution 0.65% (PRN), Lubricant Eye Drops Ophthalmic Solution 0.4-0.3% (PRN), Tension Headache Oral Tablet 500-65 MG (PRN), Triple Antibiotic External Ointment 5-400-5000 (PRN), and Vicks Vaporub Ointment 170 GM (PRN). 2. The February 2021 MAR for resident 1 is lacking diagnosis, condition, or specific indications for administration of the drug or supplements listed below: Atorvastatin Calcium oral tablet 20 MG, Bupropion HCI oral tablet 100 MG, DOK Oral Capsule 100 MG, Lubricant Eye Drops Ophthalmic Solution 0.4-0.3%, Quetiapine Fumarate Oral Tablet 25 MG, Tamsulosin HCI Oral Capsule 0.4 MG, Tension Headache Oral Tablet 500-65 MG, Vitamin B-12 tab 1000 TR, Alka-Seltzer Original #36 (PRN), Antacid Calcium Tablet Chewable 500 MG (PRN), Deep Sea Nasal Spray Nasal Solution 0.65% (PRN), Lubricant Eye Drops Ophthalmic Solution 0.4-0.3% (PRN), Tension Headache Oral Tablet 500-65 MG (PRN), Triple Antibiotic External Ointment 5-400-5000 (PRN), and Vicks Vaporub Ointment 170 GM (PRN).
Plan of Correction:	What has been done to correct? Audit of all resident orders is being conducted to ensure that all orders have a diagnosis assigned. Person Responsible: RCD, ARCD or designee