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: Sept. 14, 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 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 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

Technical Assistance:

The LIs and Administrator had a discussion regarding cleaning staff reports to management for replacement of items in resident bathrooms, UAIs, and methods of documenting procedures (i.e. blood pressure readings). If the renewal application has not yet been sent in, please do so ASAP. The current license expires on 10/17/2022.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/14/2022, 9:15 am to 2:50 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: 50 (34 in AL, 16 in Memory Care) The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4, 2 companions, all new staff background checks Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Additional Comments/Discussion: No change in circumstances for Allowable Variance for windows in historic section of building. 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 #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to obtain some required resident personal and social information. EVIDENCE: 1. The file for resident 2, admitted on 10/25/2022, lacks information regarding the resident?s current behavioral and social functioning, including strengths and problems. The section of the form the facility uses to document this information is marked N/A (not applicable).
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 resident?s current behavioral and social functioning, including strengths and problems is complete with correct information. How will occurrence be prevented? Resident Personal and Social Data sheets will be checked at resident move in to ensure that the resident?s current behavioral and social functioning, including strengths and problems is complete. Person Responsible: ED, BOM or designee
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to address an assessed need on the updated individualized service plan (ISP). EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 8 dated 8/2/2022, shows this resident is disoriented to place, time, and situation some of the time. The ISP for resident 8 dated 3/4/2022 does not address what services are given for the disorientation. It restates what the need is.
Plan of Correction:	What has been done to correct? The ISP for resident 8 has been updated to address the services given for the disorientation. How will occurrence be prevented? ISP?s will be reviewed to verify that all disorientation needs of the resident are met and documented. Person Responsible: RCD, ARCD, ED or designee
Standard #:	22VAC40-73-620-B
Description:	Based on documentation review, the facility failed to have an onsite oversight of special diets. EVIDENCE: 1. The most recent dietitian oversight of special diets dated 6/10/2022 stated, in the first paragraph, that it was done virtually.
Plan of Correction:	What has been done to correct? The dietician is scheduled to complete her next oversight of special diets onsite. How will occurrence be prevented? Dietician oversight will be completed onsite moving forward. Person Responsible: ED, RCD or designee
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review and staff interview, the facility failed to ensure medications were administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 4 contained a physician?s order, dated 06/02/2022, for Selan Cream apply topically to buttocks for prevention with brief changes and twice daily. During medication cart audit with staff 2 during on-site inspection on 09/14/2022, staff 2 stated to the LI that the aforementioned medication was not available in the facility. The September 2022 medication administration record (MAR) for resident 4 contained a note on 09/01/2022 and 09/02/2022 that the medication was not in the cart and a note on 09/03/2022 that stated ?Invalid Med (No RX or DC?d); however, the September 2022 MAR contained initials from staff on all other days two times daily that the medication was applied to the resident. Staff 2 stated that this was not accurate as the cream has not been in the facility during September 2022.
Plan of Correction:	What has been done to correct? Provider was notified regarding resident 4 and order was discontinued on 9/14/22 due to area healed. Medication Error was completed on 9/23/22 How will occurrence be prevented? Staff education on ensuring all scheduled and PRN meds are in medication cart at all times. All RCD/ARCD will complete a med pass observation with all RMAs and provide education if needed. Person Responsible: RCD, ARCD, ED or designee
Standard #:	22VAC40-73-680-E
Description:	Based on resident record review and staff interview, the facility failed to ensure medical procedures ordered by a physician or other prescriber were maintained in the resident?s record. EVIDENCE: The record for resident 2 contained a physician?s order, dated 04/03/2022, for the following: ?check blood pressure and pulse twice daily and fax results to (physician) at (fax number) every Tuesday?. During on-site inspection on 09/14/2022, the blood pressure and pulse for 09/13/2022 from 7:00AM to 3:00PM for the resident was not maintained in the resident?s record and also the record did not contain documentation that the resident?s blood pressure and pulse readings had been faxed to the physician on Tuesday 09/13/2022 as required by the physician?s order. Interview with staff 5 confirmed the aforementioned information was accurate.
Plan of Correction:	What has been done to correct? Provider was aware of not receiving resident 2 blood pressure and pulse and blood pressure and pulse for 9/13/22 3pm -9/20/22 7:00 am was sent to the provider Medication Error was completed on 9/23/22 How will occurrence be prevented? Staff education regarding the system and following physician orders. Person Responsible: RCD, ARCD, ED or designee
Standard #:	22VAC40-73-860-I
Description:	Based on observation, the facility failed to ensure that cleaning supplies were kept in a locked place. EVIDENCE: 1. The cleaning cart outside room 211 was open and unattended, with disinfectant, furniture polish, and other cleaning agents accessible to residents.
Plan of Correction:	What has been done to correct? Housekeeping cart was locked while LI was present. How will occurrence be prevented? Additional Training has been completed for housecleaning staff on the importance of keeping unattended chemicals locked inside of the housecleaning carts. Person Responsible: MD, ED or designee
Standard #:	22VAC40-73-950-E
Description:	Based on document review and interview, the facility failed to have a semi-annual review of the emergency preparedness and response plan with all residents. The documentation is required to be signed and dated. EVIDENCE: 1. Staff 6 stated that the review of the emergency preparedness and response plan for residents was done at the resident council meeting. The council meeting notes dated 6/22/2022 show that this was attended by eight (8) residents, and the facility has 50 residents. The first names of the residents are typed in, and there are no signatures.
Plan of Correction:	What has been done to correct? The Emergency Preparedness and Response Plan has been reviewed with all residents and all have signed that they have completed. How will occurrence be prevented? Semi-annual Review of the Emergency Preparedness and Response Plan will be completed will all residents and they will sign a sheet verifying the review. Person Responsible: RCD, ARCD, ED or designee