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: Dec. 19, 2019 and Feb. 5, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

An unannounced complaint inspection was conducted by a Licensing Representative on December 19, 2019 from 1:17 p.m. to 5:13 p.m. and February 5, 2020 from 11:00 a.m. to 5:24 p.m. alleging there was not enough staff to provide care, staff not handling resident care appropriately, and staff not having appropriate qualifications. There were 66 residents in care on December 19, 2019 and 64 residents in care on February 5, 2020. The following was discussed during inspection: initial staff training hours, completion of staff initial orientation documentation, allergy reactions of residents, Individualized Service Plan (ISP) including all required information, fall risk ratings, resident agreement, justification for placement and required number of activities for residents residing in the safe, secure environment, and physician?s telephone order completion. The complaint is valid. 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.

Violations:

Standard #:	22VAC40-73-1130-C
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure during night hours, when 23 to 32 residents are present, at least three direct care staff members are awake and on duty at all times in the special care unit (SCU). Evidence: 1. The ?Care Staff Assignment? documented two direct care staff worked on the SCU, and one direct care staff ?floated? between the assisted living unit and SCU during the night hours. The staff who ?floated? was not on duty at all times in the SCU during the ?NOC [night] shift? (11:00 p.m. ? 7:00 a.m.) on the following dates with the following number of residents in care: a. 12/01/19 (29 residents), 12/28/19 and 12/29/19 (30 residents) ? staff #1 and staff #2, with staff #3 ?floating.? b. 12/14/19 (30 residents) ? staff #1 and staff #4, with staff #5 ?floating.? c. 12/15/19 (29 residents) ? staff #1 and staff #2, with staff #5 ?floating.? d. 12/24/19 (29 residents) and 12/27/19 (30 residents) ? staff #7 and staff #8, with staff #3 ?floating.? e. 12/26/19 (30 residents) ? staff #6 and staff #7, with staff #3 ?floating.? 2. Staff #9 acknowledged the required number of direct care staff were not on duty at all times in the SCU.
Plan of Correction:	Director of Nursing and or Designee, in conjunction with facility's Scheduler, will ensure staffing schedules/assignments in the Special Care Unit during Night hours are appropriate as per current census. When 23 to 32 Residents are present, at least three direct care staff members will be awake and on duty.
Standard #:	22VAC40-73-200-C
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure that direct care staff met requirements of qualifications within two months of employment. Evidence: 1. Staff #10?s date of hire was 09/19/19 as a Resident Care Associate (direct care staff). Staff #10 did not have documentation of the required qualifications at the time of hire in the staff?s record or in the facility. 2. Staff #10 completed a direct care staff training course on 01/27/20, 4 months after employment began. 3. Staff #9 stated that staff #10 worked as direct care staff from date of hire until 01/27/20, and acknowledged there was no documentation of required qualifications within two months of employment.
Plan of Correction:	Direct care staff will provide the Business Office Manager, during interview process, documentation that they met requirements of qualifications prior to the hiring protocol. Business Office Manager will copy certification and insert into the employee file accordingly. A content check-off list will be initialed by the Business Office Manager prior to New Hires' start date and initialed by the Senior Executive Director and/or designee before Employee record is filed.
Standard #:	22VAC40-73-810-B
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure the resident had reasonable access to a nonpay telephone on the premises. Evidence: 1. A complaint received by the regional licensing office on 12/07/19 stated resident #1 was not being allowed to utilize a telephone as facility staff were not permitting her to do so. 2. Resident #1?s ?Progress Notes? dated 12/21/19 documented, ??Resident [resident #1] says [resident #1] can?t make calls and does not want to be here.? The note was signed by staff #11. 3. Staff #9 stated during interview ?resident [resident #1]?s phone usage has been restricted due to calls to 911 and other nuisance calls, with permission by her legal representative.? 4. There was no documentation in resident #1?s record or in the facility documenting notification of phone restriction by resident?s legal representative. 5. There was no facility policy regarding phone usage or restrictions. 6. Staff #9 observed and confirmed resident #1 did not have documentation of approval by a legal representative to restrict phone usage, nor was there a facility policy to address the resident?s phone use.
Plan of Correction:	Director of Nursing and or Designee will ensure that documentation relative to restricting phone usage by a Resident in the Special Care Unit is on the Residents' ISP. A copy of confirmation of communication to the appropriate legal representative will be filed in the Residents' Administrative File and direct care staff will be made aware of the policy of a Resident with certain phone restrictions.