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: Feb. 28, 2022

Complaint Related: No

Areas Reviewed:

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

Comments:

On 2/28/2022 one inspector conducted a monitoring visit regarding a self-reported incident. One resident record and other documents were viewed, there was a walk through of parts of the building, and one staff member was interviewed. An informal exit meeting was held on the day of the inspection, and a telephone exit meeting was held with the Administrator and Resident Care Coordinator (RN) on 3/7/2022.

Violations:

Standard #:	22VAC40-73-460-D
Description:	Based on resident record review and document review, the facility failed to provide supervision, including attention to specialized needs such as wandering, for a resident. EVIDENCE: 1. The Uniform Assessment Instrument (UAI) and individualized service plan (ISP) both show that resident 1 wanders, is exit seeking, and tries to open all doors in the safe secure unit (Memory Care). The UAI dated 2/12/2021 (in effect at the time of the incident) shows resident 1 has a behavior of Wandering/Passive - weekly or more with a note of "wanders daily", and is disoriented to some spheres, all the time. The individualized service plan (ISP) updated on 2/12/2021 (in effect at the time of the incident) shows resident 1 must reside in a safe, secure environment. "[Resident 1] has been assessed with diagnosis of Dementia and cannot protect their own health, safety and welfare or themselves from danger. Locked unit with proper staff in will be provided for safety", and that resident 1 is to have services for wandering behavior. "With increase anxiety [resident 1] tends to wander up and down corridors. Will push on doors to try to get out of the building. Staff to redirect and engage in activities." The same ISP also shows that exit seeking behaviors will be identified by staff and reduced with an activity. 2. An incident report sent to the Department on 12/16/2021 shows that resident 1 "eloped from the Memory Care Neighborhood and the community" on 12/15/2021 at 4:27 pm. The temperature was approximately 56 degrees Fahrenheit (F) at 4:30 pm and 52 F at 5 pm. The complete incident report dated 12/22/2021 shows that the malfunction of the magnetic lock on the main door to Memory Care and the time resident 1 left the unit was determined by viewing video of the Memory Care entrance area. The report also states that after leaving Memory Care, resident 1 left the building by walking out of an alarmed door. 3. An interview with staff 1 reveals that staff on the concierge desk did not respond to the alarm that went off when resident 1 left the building through a dining room door. An undated summary of the incident from the facility shows that the concierge failed to report the alarm for 30 minutes. 4. The police report dated 12/15/2021 shows that at approximately 4:55 pm they sent an officer to do an Urgent Welfare Check on resident 1, who was in a store approximately 9/10th of a mile away from the facility.
Plan of Correction:	What has been done to correct? 1. Concierge was terminated. How will recurrence be prevented? 1. The resident?s ISP has been updated to include successful interventions for resident when exit seeking. 2. Staff will be trained to perform interventions to prevent resident from exit seeking. 3. Additional training on elopement procedures was provided to staff. 4. Elopement drills will be performed on all three shifts for three months a quarterly there after. 5. An alarm was added to the door that malfunctioned that will alarm anytime that the maglock is unengaged for 20 seconds and will continue until reengaged. Person Responsible: ED, RCD, ARCD or designee
Standard #:	22VAC40-73-870-A
Description:	Based on staff interview and document review, the facility failed to have the interior of the building maintained in good repair. EVIDENCE: 1. An interview with staff 1 reveals that the main magnetic locking door to the safe, secure unit (memory care) did not function on 12/15/2021 because it didn't close enough to allow the lock to engage. When reviewing the video, staff 1 saw a staff person leave, and approximately 10 minutes later resident 1, a memory care resident, opened the door and left the secure unit. 2. A service invoice dated 1/11/2022 shows that the door closer on the main memory care door was adjusted on 12/16/2021. The repair person tested the door and it worked after work was completed. 3. A service invoice dated 2/15/2022 shows that on 2/14/2022 the door closer and latch were broken; this was discovered when an alarm was being installed on the main door to safe, secure unit. The new alarm will sound at the door if it does not shut within 20 seconds of being opened, and the lock and door closer were replaced.
Plan of Correction:	What has been done to correct? 1. An alarm was added to the door that malfunctioned that will alarm anytime that the maglock is unengaged for 20 seconds and will continue until reengaged. How will recurrence be prevented? 1. We will establish a baseline for the amount of time it takes for the door to close. The door will be tested within the same parameters each month going forward to be sure the door is closing properly. Person Responsible: Maintenance Director, ED or designee