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. 12, 2023

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

Comments:

Type of inspection: Renewal Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 09/12/2023 9:00AM until 4:00PM 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: 56 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 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication carts, medication administration pass, activities 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-660-A
Description:	Based on observation, the facility failed to ensure that when medications and dietary supplements are administered by the facility, the storage area shall be locked and single-use and dedicated medical supplies and equipment shall be appropriately stored. EVIDENCE: 1. On the morning of inspection, collateral 1 completed a walk-through of the memory care unit. 2. At approximately 9:25AM, collateral 1 observed that there were two residents sitting at tables in the dining room. Collateral 1 also observed that the MED PREP room was adjacent to the dining room and that the MED PREP room door was unlocked. The inside of the MED PREP room contained a shelf with boxes of safety lancets, safety pen needles, safety syringes, and two 64-ounce bottles of Drug Buster Drug Disposal System liquid. The inside of the MED PREP room also contained an unlocked refrigerator which contained five insulin pens, containers of Ensure nutrition shakes, and containers of Boost nutritional shakes. Collateral 1 did not observe any direct care staff within sight of the residents in the dining room or the MED PREP room. 3. A later interview with staff person 7 revealed that the MED PREP room is to always be locked.
Plan of Correction:	What has been done to correct? The doorknob to the medication closet has been replaced with a coded doorknob that will automatically lock when the door is closed. How will recurrence be prevented? Staff will be trained to check the door behind themselves to ensure that the door has latched. Over the next 30 days, the RCD/ARCD/designee will complete regular, random checks to door to assure it is closed and locked. If concerns are observed, these will be addressed immediately. Person Responsible: RCD, ARCD, ED, MD or designee Date to be corrected: 11/4/2023
Standard #:	22VAC40-73-950-E
Description:	Based on resident record review and staff interview, the facility failed to ensure that all residents took part in a semi-annual review of the emergency preparedness and response plan with documentation of signatures and dates of completion. EVIDENCE: Interview with staff person 5 during on-site inspection on 9/12/2023 at approximately 11:11AM, indicated that the facility did not obtain signatures and dates from residents for the review of the facility?s emergency preparedness and response plan. There was no documentation of signatures and dates of residents? completion of this review.
Plan of Correction:	What has been done to correct? The facility?s emergency preparedness and response plan will be reviewed with new and current residents as per regulatory standards. Signatures will be obtained from resident and/or responsible party to demonstrate awareness to facility?s plan. This review will occur by 10/31/2023. How will recurrence be prevented? Going forward the facility?s emergency preparedness and response plan will be reviewed with current and new residents and documented with signatures and dates at least twice per year and as needed to assure continued compliance with regulatory standards. Person Responsible: ED/designee Date to be corrected: 10/31/23