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: Dec. 15, 2023

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: 12/15/2023 9:54AM until 11:15AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 11/03/2023 regarding allegations in the area of: resident care and related services. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-640-A
Description:	Based on facility document review, resident record review, and staff interview, the facility failed to ensure that it implemented its written plan for medication management. EVIDENCE: 1. The facility?s medication management plan provided to the licensing inspector (LI) by staff 1 on 12/15/2023 indicates in section ?Med 10 ? Handling, Ordering, and Refilling Medications? that no resident shall be allowed to take another?s medication, nor shall staff be allowed to give one resident?s medication to another resident. 2. The record for resident 1 contains a physician?s order, dated 10/27/2023, for morphine take the contents of one prefilled syringe (0.25ML=5MG) by mouth or under tongue every three hours as needed for pain or shortness of breath and a physician?s order, dated 10/27/2023, to discontinue current morphine order every three hours and start morphine take the contents of two prefilled syringes (0.5ML =10MG) by mouth or under tongue every two hours as needed for complaints of pain and/or shortness of breath. 3. The record for resident 2 contains a physician?s order, dated 06/19/2023, for morphine take 0.25ML (5MG) by mouth or under tongue every three hours as needed for pain or shortness of breath. 4. The record for resident 1 contains documentation that resident 1 was administered morphine that was prescribed for resident 2 by the following staff persons: staff person 2 on 10/27/2023 at 9:39PM and 11:00PM; staff person 3 on 10/27/2023 at 11:30PM; staff person 4 on 10/28/2023 at 1:50AM, 3:50AM, and 5:50AM; staff person 5 on 10/28/2023 at 7:50AM, 9:50AM, 11:50AM and 1:50PM and staff person 6 on 10/28/2023 at 3:50PM. Interview with staff person 3 on 12/15/2023 confirmed that this was accurate.
Plan of Correction:	What has been done to correct? Staff have been retrained on the Commonwealth Senior Living Medication Policy of not utilizing medications for other residents. Also retraining was completed on the proper way to order medications with a focus on ordering medications after business hours. How will reoccurrence be prevented? Staff involved have been counselled to ensure they understand the implications of not following the Commonwealth Senior Living Medication Plan. Staff involved will attend 4 Hour Medication Refresher Course.