VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Georgian Manor
651 River Walk Parkway
Chesapeake, VA 23320
(757) 436-9618

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: May 3, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 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

Comments:

This was an unannounced Renewal Inspection conducted by Licensing Inspectors. This Inspection was conducted on 05/03/2019 ( 8:35 a.m. - 4:41 p.m.) During the inspection a medication observation was conducted, a tour of the facility and staff and resident records were reviewed including criminal background check for all new employees since last inspection that are currently employed by the facility. Licensing Inspector conducted resident's interviews. The Healthcare Oversight Report, Dietician Report, Emergency Evacuation Drills, Fire Inspection, Health Inspection, and Emergency Preparedness and Response Plan were reviewed during the inspections. There were 65 residents in care during the inspection. There were violations cited on the areas of Personnel, Resident Care and Related Services, Building and Grounds, Emergency Preparedness and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairment. Discussion During Inspection: 1. The area in back of the facility outside there is a stream which has nothing blocking it currently. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain 1.) Steps to correct the noncompliance with standards (s) 2.) Measure to prevent the noncompliance from occurring again; and 3.) Person (s) responsible for implementing each step and/ or monitoring any preventive measures (s). Please send your corrective plan to me in a Word Document by 05/22/2019 or sooner. Thank you.

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on record review and interview, the facility failed to ensure that prior to admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. Resident # 6 (date of admission 04/15/2017) was moved to the Special Care Unit (SCU), Sweet Memories, on 04/26/2019, without an assessment by a psychologist or physician. 2. Staff # 1 confirmed they did not have documentation of an assessment for resident # 6 for placement into the SCU.
Plan of Correction:	Cognitive Impairment physician documentation will be obtained and put in the resident?s medical file upon receipt. This relocation of this cited Assisted Living Resident to Memory Care was an emergency basis for safety?s sake due to her exiting of the building and confusion. Family has a Neurologist appt. set for May 30th, 2019 as it was the only available appointment. Random audits of charts will be completed by either the Senior Executive Director, Resident Care Director or Assistant Resident Care Director.
Standard #:	22VAC40-73-120-A
Description:	Based on record review and interview, the facility failed to ensure orientation and training required in subsections B and C is to occur within the first seven working days of employment. Evidence: 1. Staff # 4 ( hired on 12/05/2017) record revealed that staff # 4's orientation was signed as being completed on 12/18/2017. 2. Staff # 5 acknowledged staff # 4's orientation was not conducted until 13 days after beginning of work.
Plan of Correction:	It will be the responsibility of the Business Office Manager to ensure all new staff will receive orientation and training within the first seven working days of employment and documented accordingly in the Associates Employee File. The Sr. Executive Director, Resident Care Director and or designee will monitor this action.
Standard #:	22VAC40-73-440-A
Description:	Based on record review and interview the facility failed to complete the UAI whenever there is a significant change in the resident's condition. Evidence: 1. Resident # 2's Uniform Assessment Instrument (UAI) dated 12/30/2018 indicated resident requires mechanical help only for mobility, but ISP dated 01/16/2019 indicates resident requires mechanical help and human help, supervision for mobility. Staff # 1 confirmed resident # 2's Individualized Service Plan (ISP) is what should be reflected on the UAI.
Plan of Correction:	The Resident Care Director or designee will ensure that each ISP is reviewed and updated annually or if there?s a change in condition. Resident 2?s UAI was updated to be a mirror-image of her ISP. The Sr. Executive Director or Designee will complete random audits in an effort to prevent from happening in the future. Date to be corrected: 5/13/19
Standard #:	22VAC40-73-450-F
Description:	Based on record review and interview, the facility failed to ensure that Individualized Service Plans (ISPs) is reviewed and updated once every 12 months and as needed as the condition of the resident changes. Evidence: 1. Licensing Inspector (LI) observed that Resident # 1's Fall Risk Rating tool documented post-falls on 08/10/2017 and 03/10/2018. Resident # 1's Individualized Service Plan (ISP) dated 01/16/2019 indicates that resident was identified as a fall risk on 06/30/ 2017, with no updates post-falls reflected on the ISP. 2. Resident # 2's ISP dated 01/16/2019 indicated resident # 2 is on a regular diet; however, resident?s Dietary Communication Form (dated 05/30/2017) indicated resident is on a ?No added salt (NAS) diet approximately 4-6 grams of sodium" which was not reflected on the ISP. 3. Resident # 3 had falls documented on the Fall Risk Rating form on 04/26/2019, 04/29/2019 and 05/02/2019. However, resident # 3's last ISP update on 04/25/2019 had no new interventions reflected on the ISP. 4. Resident # 4's Uniform Assessment Instrument ( UAI) dated 12/30/2018 documented resident # 4 is disoriented to place. However, the ISP does not address resident # 4's orientation needs. 5. Resident # 5's record indicated resident is self-care for his foley catheter; however, his ISP dated 01/16/2019 indicated resident requires mechanical and human help, physical assistance. Staff # 1 told LI that resident # 5 receives home health assistance with foley care which was not reflected on the ISP. 6. Resident # 7's UAI dated 03/09/3019 for toileting indicated Mechanical Help and resident's ISP dated 03/07/2019 indicated resident # 7 was independent with toileting. Staff # 1 told LI that the ISP should have Mechanical Help only which was not reflected on the ISP. 7. Resident # 10's UAI dated 12/08/2018 indicated resident # 10's Needs Help Mechanical & Human Help Physical Assistance. However, the ISP dated 12/08/2018 did not reflect resident's mobility. 8. Staff # 1 acknowledged the ISPs had not been updated to reflect the resident's changes.
Plan of Correction:	Residents 1,2,3,4,5,7 & 10 ISP?s were updated to reflect assessed needs. Community will continue to complete preliminary ISP and Comprehensive ISP in conjunction with resident, family and or caregivers while using the History & Physical, physician orders, UAI and other support to ensure the individualized basic needs of the resident are adequately identified to include type of assistance needed to protect the residents? health, safety, type of assistance required by coordinated services if applicable and required signatures. Sr. Executive Director will review the preliminary ISP on the date of admission. Sr. Executive Director, Resident Care Director and or designee shall review other ISP?s to ensure compliance. Sr. Executive Director will complete random monthly audit of a minimum of 5 comprehensive ISP?s to ensure ongoing compliance .
Standard #:	22VAC40-73-870-A
Description:	Based on observation and interview the facility failed to ensure the interior of the building is maintained and in good repair. Evidence: 1. Licensing Inspector (LI) with staff # 6 observed the following during the tour of the facility: a. The hallway in the back ceiling vent had brown stains around it. b. Between room # 60-61; near the living room the paint was cracking and peeling at the top of the ceiling. c. Near the kitchen the ceiling tile was cracking on the assisted living side of the facility. d. In room # 3 above the door the paint was cracking. The paint was cracking above the chair rail. There were four slates broken on the blinds in the room. e. In the Special Care Unit ( SCU) in the dining area there were black marks on the wall at the bottom of the chair rail. f. Near rooms # 10, # 11 and # 13 there were darks spots on the carpet in the hallway. g. In the Alice Hall located in the SCU the chiar railing was chipping along the wall. h. Room # 16 the soap dispenser is loose. i. Room # 20 the chair rail was chipping j. In the hall area called the Fifty's there was black stains on the walls below the chair railing. 2. Staff # 6's acknowledged the areas during the tour of the facility.
Plan of Correction:	The Maintenance Director walked the perimeter of the building and all observations by the Licensing Inspector were noted and shall be corrected accordingly and maintained going further. A daily walk-thru by Directors will be instituted to keep maintenance up to date on upkeep.
Standard #:	22VAC40-73-950-C
Description:	Based on record review and interview the facility failed to implement an orientation and semi-annual review on the emergency preparedness and response plan for all residents. The review shall be documented by signing and dating. Evidence: 1. Licensing Inspector (LI) reviewed facility's emergency preparedness with staff # 1 and observed there was no documentation that was signed and dated indicating that the review of the emergency preparedness was conducted for the residents. 2. Staff # 1 confirmed there was no documentation for the residents of the facility's emergency preparedness.
Plan of Correction:	The Program Director and or designee will maintain the Residents? record of attending the Emergency Preparedness in service and obtain required signatures.