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: June 9, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/9/2022, 11:40 am to 1:05 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 42 The licensing inspector completed an observation of three medication carts. Number of resident records reviewed: one Number of interviews conducted with staff: three An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Susan Mallory, Licensing Inspector at (540) 309-3043 or by email at susan.mallory@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to administer medication in accordance with the physician?s order. EVIDENCE: 1. An order for resident 1 signed on 2/24/2022 states ?Novolog 100 unt/ml Flexpen, inject 5 units sub-Q twice daily with lunch & dinner? Hold if blood sugar is less than 100.? The medication administration record (MAR) for April 2022 for resident 1 shows that blood sugar (blood glucose ? BG) was below 100 on: 4/3 at 4 pm 87 BG, and the MAR exceptions does not show that the Novolog was withheld. The MAR for May 2022 for resident 1 shows that BG was below 100 on: 5/28 11:30 am 89 BG, 5/29 11:30 am 99 BG, and 5/31 11:30 am 63 BG, and the MAR exception report does not show that the Novolog was withheld. The MAR for June 2022 for resident 1 shows that BG was below 100 on: 6/1 at 11:30 am 76 BG, 6/2 at 11:30 am 92 BG, 6/4 at 11:30 am 83 BG, and 6/7 at 11:30 am 89 BG, and there is no MAR exception report, and no other documentation to support that the Novolog was withheld as ordered.
Plan of Correction:	Not available online. Contact Inspector for more information.