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: June 18, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced monitoring inspection was conducted by two Licensing Inspectors from the Eastern Region on June 18, 2019 from 10:00 a.m. to 3:41 p.m. There were 69 residents in care. Resident records reviewed and interviews conducted during the monitoring inspection. The following was discussed during the inspection: Staff training for using assistive devices due to 2 resident injuries noted while using wheel chair, timeframes for completing the review of appropriateness, falls and interventions implemented, reviewing admission paperwork thoroughly prior to admission to determine facility?s ability to meet resident needs, and documenting that the doctor and family are aware of relocations from Safe Secure Environments to Assisted Living. Please submit your ?plan of correction? and ?date to be corrected? by 7-17-2019 for each violation cited and return all inspection reports signed and dated within 10 calendar days. The plan of correct must indicate how the violation will be or has been corrected. Just writing the word ?corrected? is not acceptable. The plan of correction must include: 1. Step(s) to correct the noncompliance with the standard(s) 2. Measures to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative measures. If you have any questions, please contact your inspector Alexandra Poulter at 757-613-5133 or by email at alexandra.poulter@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-460-D
Description:	Based on record review and interview, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls. Evidence: 1. During record review, the following was observed: A. Resident #1?s Individualized Service Plan (ISP) dated 05-13-19 documented the resident is at risk for falls. a. Resident?s admission physical exam dated 03-19-19 documented the resident has a diagnosis of syncope. b. Resident?s record revealed the resident had eight falls since admission (03-25-19) on 04-17-19, 04-18-19, 04-26-19, 04-29-19, 05-02-19, 05-20-19, 05-24-19 and 06-13-19. c. A hospital discharge note documented the resident was sent to the hospital after the fall on 04-26-19 and returned with a diagnosis of ?closed head injury due to fall.? B. Resident #2?s ISP dated 12-08-18 documented the resident is at risk for falls. a. The facility?s narrative charting and fall risk ratings documented the resident had four falls on 11-16-18, 12-17-18, 05-10-19, and 05-15-19. b. Narrative charting documented the resident also had a witnessed fall out of the wheelchair on 05-16-19 while being transported by staff, which resulted in two rib fractures and admission to the hospital. C. Resident #3?s ISP dated 01-05-19 documented the resident is at risk for falls. a. Fall risk ratings and narrative charting documented the resident was found on floor 02-04-19, 05-02-19, 05-24-19, 06-05-19 (twice on that date,) and 06-16-19 and had falls on 01-01-19, 01-24-19, 01-25-19, and 03-08-19. b. Resident was admitted to the hospital 05-24-19 for subdural hematoma, and on 06-16-19 per interview it was stated that the resident is now required to wear a soft helmet. D. Resident #4?s ISP dated 05-02-19 documented the resident is at risk for falls. a. Narrative charting documented the resident was found on the floor 02-04-19, 04-04-19, 04-10-19, 04-15-19, 05-31-19, 06-08-19, and 06-14-19; Narrative charting documented the resident fell on 03-23-19, 04-06-19, 04-26-19 (twice), 05-09-19, and 05-21-19. b. The fall on 05-21-19 resulted in a diagnosis of ?closed head injury and laceration to scalp? and resulting in the resident receiving sutures. 2. Staff #1 confirmed resident #1, resident #2, resident #3, and resident #4 frequency of falls and number of times residents were found on the floor.
Plan of Correction:	What Has Been Done to Correct? Resident fall risk assessments will be completed as per regulatory standards and any required additional interventions will be implemented such as frequent monitoring, physical therapy, fall mats and engaging Residents in programming activities for participation & supervision. A Personal one-to-one sitter may be instituted with the Residents? family member/POA to ensure safety needs are met. How Will Recurrence Be Prevented? There will be weekly reviews of falls encountered to ensure fall risk assessments are updated and appropriate interventions put into place and indicated on the Residents? ISP. Residents with multiple falls will be considered for higher level of care and possible discharge from the Community. Person Responsible: Resident Care Director and/or Assistant Resident Care Director
Standard #:	22VAC40-73-460-E
Description:	Based on record review and interview, the facility failed to ensure that Individualized Service Plans (ISP) were reviewed and updated as needed as the condition of the resident changes. Evidence: 1. During review of resident #5?s record, physical therapy (PT) notes dated 02-20-19, 05-02-19, 05-10-20, 05-13-19, and 05-16-19 documented the resident was receiving assistance with transfers from PT; however, the resident?s ISP dated 06-19-18 documented the resident was independent in transferring. 2. Staff #3 was present during record review and confirmed PT notes regarding transfer training and discrepancy documented in the ISP.
Plan of Correction:	What Has Been Done to Correct? Resident fall risk assessments will be completed as per regulatory standards and any required additional interventions will be implemented such as frequent monitoring, physical therapy, fall mats and engaging Residents in programming activities for participation & supervision. A Personal one-to-one sitter may be instituted with the Residents? family member/POA to ensure safety needs are met. Resident 5?s ISP was updated to reflect he is no longer independent with transferring. How Will Recurrence Be Prevented? There will be weekly reviews of falls encountered to ensure fall risk assessments are updated and appropriate interventions put into place and indicated on the Residents? ISP. Residents with multiple falls will be considered for higher level of care and possible discharge from the Community. Person Responsible: Resident Care Director and/or Assistant Resident Care Director