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: March 31, 2022

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 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:

On 3/31/2022 two inspectors conducted an onsite renewal study (9 am to 4:30 pm). 40 residents were in care. Eight resident records and four staff records were fully reviewed. Partial records and other records were reviewed. Residents and staff were interviewed, a medication pass was observed, and a physical plant tour was done. An exit interview was held onsite the day of the inspection and the facility was given an opportunity to submit additional documentation. A final telephone interview was held on 4/7/2022 with the Executive Director (Administrator).

Violations:

Standard #:	22VAC40-73-210-F
Description:	Based on staff record review, the facility failed to ensure that staff had at least two hours of training in infection control included in annual training. EVIDENCE: 1. Training records for staff 2 don't document at least two hours of infection control training for the most recent training year (7/15/2020 to 7/14/2021). One half-hour of infection control training was documented in this time period for staff 2. 2. Training records for staff 4 do not document any infection control training for the most recent training year (5/20/2020 to 5/19/2021).
Plan of Correction:	What has been done to correct? 1. Training year (7/15/2020 to 7/14/2021) is past. Staff member #2 will have completed the required two-hour infection control training for the current training year (7/15/2021 to 7/15/2022). 2. Training year (5/20/20 to 5/19/2021) is past. Staff member #4 will have completed the required two-hour infection control training for the current training year (5/20/2021 to 5/19/2022). How will recurrence be prevented? Training will be monitored and if staff have not completed the required training within the training year, they will be taken off the schedule until the training is complete. Person Responsible: ED, RCD, ARCD or designee
Standard #:	22VAC40-73-290-A
Description:	Based on staff schedule review, the facility failed to indicate on the schedule which staff person was in charge at any given time. EVIDENCE: 1. The written staff schedule for 3/25/2022 and 3/29/2022 does not indicate who is in charge during third shift for these two days.
Plan of Correction:	What has been done to correct? The schedule has been updated to reflect which staff member is in charge on each shift. How will recurrence be prevented? Schedules will be reviewed weekly to ensure that a supervisor is identified for each shift. Person Responsible: RCD, ARCD, ED or designee
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure that the physical examination report contained all required components. EVIDENCE: 1. The Resident Physical Examination Report for resident 1, dated 06/30/2021, did not contain a statement that specified whether the resident is or is not capable of self-administering medication.
Plan of Correction:	What has been done to correct? 1. Order from Dr. has been obtained that resident 1 requires assistance with administration, storage, and monitoring of medications. 2. TB evaluation form has been dated by physician for resident 4- this was dated when it was completed prior to admission on 2/17/22 3. Documentation stating allergies and reactions for Bupropion, Escitalopram, PCN and Ceclor and reactions has been signed by physician- this was completed by physician on 2/10/22 with unknown reactions and on 3/23/22 notification of Allergy form was updated with correct information. How will recurrence be prevented? All documentation will be checked at move in to ensure that they meet compliance. Person Responsible: ED, RCD or designee
Standard #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to ensure that personal and social information on all residents were obtained as required. EVIDENCE: 1. The resident-personal/social data sheet for resident 3, admitted 03/12/2022, did not contain the following components: admission date, clergyman/place of worship if applicable, personal physician, personal dentist, and previous mental health or intellectual disability services history, and if applicable for care or services. 2. The Resident Personal/Social Data Sheet for resident 9, admitted 8/20/2021, is lacking the following components: Admission Date, information on advance directives/DNR, next of kin, personal physician, personal dentist, current behavioral and social functioning including strengths and weaknesses. 3. The Resident Personal/Social Data Sheet for resident 4, admitted 2/18/2022 is lacking information regarding current behavioral and social functioning including strengths and weaknesses.
Plan of Correction:	What has been done to correct? Resident personal data sheets have been updated in all resident?s files to ensure that each component is complete with information or not applicable where no information is available. How will recurrence be prevented? Resident Personal and Social Data sheets will be checked at resident move in to ensure that all components on the sheet are completed with appropriate information or are marked not applicable when no information is provided. Person Responsible: ED, BOM or designee
Standard #:	22VAC40-73-410-A
Description:	Based on resident record review, the facility failed to obtain an acknowledgment from residents and their legal representatives upon admission of receiving orientation and related information for new residents. EVIDENCE: 1. The record for resident 3, admitted 03/12/2022, did not contain a signed and dated acknowledgment that the resident and her legal representatives(s) received orientation upon admission. 2. The record for resident 4, admitted 2/18/2022, lacked documentation that the call system was covered in the new resident orientation.
Plan of Correction:	What has been done to correct? 1. Resident 3 received orientation and the orientation form signed by her POA. 2. Resident 4?s RP has been oriented to the call system and has signed the orientation form. How will recurrence be prevented? All orientation documents will be reviewed prior to resident moving into the community to assure that orientation documentation has been signed and dated by the resident or responsible party to ensure that orientation has been completed. Orientation shall include mealtimes, call system and emergency response procedures. Person Responsible: ED, BOM or designee
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that uniform assessment instruments (UAIs) were completed as required. EVIDENCE: 1. The UAI for resident 3, dated 03/28/2022, indicated that the resident is disoriented some spheres, all the time with the sphere effected as time. The individualized service plan (ISP) for the resident, dated 03/28/2022, indicated that the resident ?has a current or history of occasional disorientation to time?. Interview with staff 5 confirmed that the UAI was incorrect and the ISP was correct. 2. The UAI for resident 6 dated 3/7/2022 shows the resident requires supervision with eating/feeding; the ISP dated 3/8/2022 shows the resident has both supervision and human help/physical assistance, and interview with staff 5 indicates the ISP is correct.
Plan of Correction:	What has been done to correct? 1. Correction to UAI and ISP completed on resident #3 regarding the orientation of the resident ? the UAI and ISP match 2. Correction to the UAI and ISP completed on resident #6 regarding eating and feeding- the UAI and the ISP match How will recurrence be prevented? All information will be reviewed prior to completion and ensure the UAI, and ISP match and the resident is receiving the care that is needed Person Responsible: RCD, ARCD, ED or designee
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure that individualized service plans (ISPs) contained all required components. EVIDENCE: 1. The ISP for resident 1, dated 02/16/2022 contained the following documentation for dressing, ?Staff to assist w/ lower body, to apply/remove TED hose and to fasten/unfasten clothing.? Interview with staff 5 indicated that the resident does not wear TED hose and that the ISP contained incorrect information. 2. The uniform assessment instrument (UAI) for resident 6 dated 3/7/2022 shows this resident is disoriented to time and situation some of the time. The ISP for resident 6 dated 3/8/2022 does not show what services are given for this need. The ISP dated 3/8/2022 for resident 6 shows the resident gets assistance when using the toilet, but does not address who provides the service or when and where service is to be provided. The ISP dated 3/8/2022 for resident 6 shows the resident is allergic to Biaxin, and the ISP does not address how the facility will help her not use this medication. 3. The ISP dated 3/23/2022 for resident 4 shows, in the services to be provided section, a description of a need, but does not show what services will be provided to meet the need. "Resident 4 requires 2 hour checks and resides in sweet memories". The ISP dated 3/23/2022 for resident 4 shows the resident is allergic to four medications, but does not describe what services will be provided to help the resident avoid the medications. The ISP dated 3/23/2022 for resident 4 shows that resident 4 requires supervision and/or verbal ques to evacuate resident or to request emergency assistance, but does not describe what services are given.
Plan of Correction:	What has been done to correct? 1. Correction to resident #1 ISP regarding TEDS hose 2. Correction to the UAI for resident #6 regarding orientation. Correction to ISP regarding who, when, and where the toileting service is provided 3. Correction to the ISP regarding allergies for resident #6 4. ISP corrected for resident #4 regarding services provided 5. ISP corrected for resident #4 regarding the services provided to help the resident avoid medications that the resident is allergic to 6. Correction to ISP for resident # 4 regarding what services are given to evacuate or request emergency assistance How will recurrence be prevented? All information will be reviewed prior to completion and ensure the UAI, and ISP match and the resident is receiving the care that is needed, the services will be listed that the resident receives Person Responsible: RCD, ARCD, ED or designee
Standard #:	22VAC40-73-560-F
Description:	Based on observation of the facility?s medication carts, the facility failed to ensure all records were treated confidentially and that information is made available only when needed for care of the residents. EVIDENCE: 1. The 2nd and 3rd floor medication cart narcotic books were observed lying on top of the second and third floor medication carts and left unattended by staff by one licensing inspector (LI) during the on-site renewal inspection on 03/31/2022. The books displayed multiple names of residents residing on the second and third floors containing documentation regarding what narcotics they are prescribed.
Plan of Correction:	What has been done to correct? Narcotic books are locked in the cart on Memory Care and Assistant Living Floors. How will recurrence be prevented? Staff Education and monitored and corrected during daily sweeps Person Responsible: RCD, ARCD, ED or designee
Standard #:	22VAC40-73-640-A
Description:	Based on observation during audit of the facility?s medication carts, resident record review and document review, the facility failed to implement their medication management plan, and cover certain contingencies in the medication management plan. EVIDENCE: 1. The facility?s medication management plan, dated 12/15/2021, states the following, ?Controlled substance shift counts ? 1. Shift counts are performed at the end of each shift or when the person responsible for medications changes.? and ?4. If the quantity is verified, the off-going and on-coming Med Aides both sign the appropriate Controlled Substance Shift Count form.? 2. The ?Narcotic Shift Count? logs for the medication carts located in the safe, secure unit and the second and third floor contained multiple days for February and March 2022 that did not contain the signatures for the off going and on coming medication administration staff. 3. The facility?s medication management plan, dated 12/15/2021, states the following, ?all multidose items shall have an open/start date. This includes creams, topicals, eye drops, ear drops, respiratory meds, powders, liquids, insulins, and nitroglycerin.? 4. The records for residents 1, 7 and 8 contained physician?s orders, all dated 02/24/2022, for latanoprost 0.005% eye drops for each of the aforementioned residents. 5. During the facility?s on-site inspection on 03/31/2022, one licensing inspector (LI) observed three opened bottles of Latanoprost 0.005% eye drops for residents 1, 7 and 8 in medication carts 2 and 3 during the medication cart audit that did not contain the date that the eye drops had been opened by staff. This was also verified by staff 1. 6. The record for resident 1 contained a physician?s order, dated 02/24/2022, for Novolog 100 unit/ML Flexpen inject 5 units sub-q twice daily with lunch and dinner for diabetes. During the medication cart audit of medication cart 3, LI observed the Novolog insulin pen that was labeled for resident 1 did not contain the date that it had been opened by staff. This was also verified by staff 1. 7. The facility's medication management plan does not cover the procedure they use when a PRN medication is needed when a nurse or medication aid is not in the building, as sometimes happens during third shift. 8. The facility's medication management plan does not cover how narcotic counts and medication cart keys are handled when there is no nurse or medication aid for a particular shift.
Plan of Correction:	What has been done to correct? Carts have been audited to ensure that all opened medication such as eye drops and Insulin pens have open dates. Actively working to update the Medication Management Plan. Once complete, it will be submitted to LI for approval. How will recurrence be prevented? Education will be provided to staff and Medication carts will be audited weekly to ensure they meet compliance. Education is being provided to staff regarding the proper procedures to complete the ?Narcotic Shift Count? logs. The logs will be audited weekly to ensure compliance. Person Responsible: RCD, ARCD, ED or designee
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to ensure that medications were administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1 contained a physician?s order, dated 02/24/2022, for Novolog 100 unit/ML Flexpen inject 5 units sub-q twice daily with lunch and dinner for diabetes and to hold if blood sugar is less than 100. 2. The March 2022 medication administration record (MAR) for resident 1 contained documentation that on 03/24/2022 the resident?s blood sugar was 86 at 4:00PM; however, Novolog was administered to the resident when it should have been held according to the physician?s order.
Plan of Correction:	What has been done to correct? Provider was notified and medication error report completed for Resident #1 How will recurrence be prevented? Education will be provided to staff and all diabetic orders with parameters will be audited. The orders for parameters will be audited weekly to ensure they meet compliance. Person Responsible: RCD, ARCD, ED, or designee
Standard #:	22VAC40-73-860-I
Description:	Based on observation, the facility failed to store cleaning supplies and other hazardous materials in a locked area. EVIDENCE: 1. At approximately 9:21AM, one licensing inspector (LI) observed under the nurses? desk located on the second floor of the facility the following cleaning products that were not located in a locked area: Microban 24 hour bathroom cleaner, Clorox Scentiva disinfecting multi-surface cleaner and a pack of Lysol disinfecting wipes.
Plan of Correction:	What has been done to correct? Cleaning Supplies and other Hazardous materials on the 2nd floor were locked in proper area How will recurrence be prevented? Staff Education and monitored and corrected during daily sweeps Person Responsible: RCD, ARCD, ED or designee