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: Sept. 20, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced monitoring inspection to investigate a complaint was conducted by two Licensing Inspectors on September 20, 2019 from 9:07 a.m. to 1:27 p.m. There were 68 residents in care. The complaint was valid. The following was discussed during the inspection: resident retention, services on the ISP. Please submit your ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it within 10 calendar days. The plan of correction must indicate how the violation will be or has been corrected. 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 alexandra.poulter@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-460-B
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure that care provision and service delivery was resident-centered to the maximum extent possible that included prompt response by staff to resident needs as reasonable to the circumstances. Evidence: 1. A complaint was received on 08-20-19 by the regional licensing office regarding an incident that occurred on or around 08-09-19 that alleged a resident was left on the toilet for more than an hour, and response continues to be poor by staff. 2. Resident #1?s current Individualized Service Plan (ISP) dated 05-16-19 documented resident ?requires assistance getting cleaned up after using toilet?. Also documented on the ISP is ?hourly room checks? dated 08-02-19; however, there was no documentation of the hourly room checks. 3. Review of the facility?s call bell log documented the following response times: A. 64 minutes for Room 41 on 07-29-19 at approximately 7:54 a.m.; B. 77 minutes for Room 41 on 07-30-19 at approximately 8:44 a.m.; 75 minutes for Room 46-A on 07-30-19 at approximately 7:45 a.m.; and C. 145 minutes for Room 27 on 08-08-19 at approximately 4:49 a.m.; 64 minutes for Room 39 on 08-08-19 at approximately 3:55 a.m.; 86 minutes for room 46-A on 08-08-19 at approximately 2:53 a.m.; and 46 minutes for Room 70 on 08-08-19 at approximately 3:22 a.m. 4. Staff #2 observed and confirmed the delayed response times to resident call bells, and stated that hourly checks are not completed on resident #1.
Plan of Correction:	Direct care staff were re-educated on the proper call bell procedures and re-educated to check out the appropriate phone for the area they will be working during their shift. Resident does not require hourly room checks and this was removed from the ISP. Residents ISP, care provision, and service delivery will be resident centered in accordance with DSS Licensing Standards. Random testing of the call bell system will be done a minimum of 1 time per week at various times by the Executive Director or designee. Executive Director or designee will also audit a minimum of 5 ISP?s per month to ensure continued compliance.