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: Nov. 30, 2020 , Dec. 1, 2020 and Dec. 2, 2020

Complaint Related: Yes

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on November 24, 2020 and concluded on December 2, 2020. A complaint was made with allegations related to staffing and call bell response times. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Executive a list of documentation required to complete the investigation. A video call was conducted to test the call bell system virtually. Records reviewed and interviews conducted. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. The staffing allegation was not be substantiated however, complaint is valid.

Violations:

Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to ensure the Medication Administration Record (MAR) included the diagnosis, condition, or specific indications for administering each drug or supplement. Evidence: 1. The following MARs did not include the diagnosis, condition, or specific indications for administering the following drugs or supplements: A. Resident #1?s October 2020 MAR for Ciprofloxacin HCI; and August 2020, September 2020, October 2020 and November 2020 MAR for Memantine HCI; B. Resident #2?s August ? November MARs for Ergocalciferol, Lactulose, Donepezil; October and November MARs for Haloperidol; and C. Resident #3?s August ? November MARs for Amino Acids, Aspirin, Jobst Antiem KN LG/RG, Vitron-C; Metolazone for September MAR; October and November MARs for Mag Oxide Tab, Docusate Sodium, and Fluticasone Propionate. 2. Staff #1 and staff #2 acknowledged during discussion that the aforementioned MARs did not include the diagnosis, condition, or specific indications for administering each drugs or supplements.
Plan of Correction:	What Has Been Done to Correct? Resident MARS will be reviewed for any missing diagnosis, condition or specific indications for administering each drug or supplement and, if necessary, House N.P. will be contacted for clarification. How Will Recurrence Be Prevented? House N.P. was advised of the violation and will ensure he indicates the necessary information when prescribing any new orders. Orders will be reviewed before forwarding to the pharmacy for accuracy. Person Responsible: Resident Care Director and/or Assistant Resident Care Director
Standard #:	22VAC40-73-870-E
Complaint related:	Yes
Description:	Based on record review and discussion, the facility failed to ensure all equipment was kept in good repair and condition. Evidence: 1. The facility?s call bell logs documented staff response times that range from approximately 10 minutes to approximately 1403 minutes. The times varied during the months of December 2019, January 2020, February 2020, September 2020, and October 2020. The following are a sampling of the documented staff response times: A. 12/24/2019, 3:20 p.m. ? 3:30 p.m. (10 mins.); 12/27/2019, 1:03 p.m. ? 3:14 p.m. (130 mins); 12/29/2019, 10:20 p.m. ? 11:08 p.m. (48 mins.); 12/30/2019, 6:14 p.m. ? 12/21 8:33 a.m. (859 mins.); B. 01/13/2020, 5:32 a.m. ? 7:52 a.m. (140 mins.); 01/17/2020, 2:44 p.m. ? 7:29 p.m. (285 mins.); 01/05/2020, 11:34 a.m. ? 01/06/2020, 10:58 a.m. (1403 mins.); C. 02/02/2020, 10:19 p.m. ? 11:36 p.m. (76 mins.); 02/11/2020, 6:05 a.m. ? 12:03 p.m. (357 mins.); 02/12/2020, 7:19 p.m. ? 02/13/2020 12:13 p.m. (1014 mins.); D. 09/17/2020, 5:09 a.m. ? 7:48 a.m. (158 mins.); 09/14/2020, 10:14 a.m. ? 4:21 p.m. (366 mins.); 09/13/2020, 5:30 p.m. ? 09/14/2020, 9:44 a.m. (984 mins.); and E. 10/15/2020, 9:36 p.m. ? 10:17 p.m. (41 mins.); 10/03/2020, 1:45 p.m. ? 4:21 p.m. (155 mins.); 10/23/2020, 6:52 p.m. ? 10/24/2020 3:22 a.m. (509 mins.). 2. Staff #1 acknowledged response variations in the call bell times that were documented in the ?Lively Home GreatCall Inc? [call bell system] reports. Additionally, Staff #1 indicated the call bells were answered however, the equipment ?was not working correctly? and not in good repair. Staff #1 could not provide documentation indicating the facility staff had knowledge of the call bell system not working properly. No documentation indicating that a repair company had been contacted for the said needed repair was provided. Additionally, Staff #1 did not provide documentation, which indicated that the call bells had been answered despite the equipment not working properly.
Plan of Correction:	What Has Been Done to Correct? All call bell pull stations & pendants have been tested to ensure batteries are in working order. We performed a test; engaging a pull station in a model room & advised Staff to not answer it in an effort to ascertain if system alerting was in working order. Vendor assured us after 90 minutes a call will be placed first to the Community followed by Resident Care Director?s cell number. An email will then be sent to the Maintenance Director stating issue was satisfied. How Will Recurrence Be Prevented? Call bell records will be reviewed daily and any discrepancies will be highlighted & investigated. A statement about the outcome will be indicated on the sheet. If discrepancies are vendor related, a call or email will be sent to our representative for resolution. All staff will be in-serviced again on the proper protocol for responding to call bells & to ensure all pull stations in a room are re-set. Person Responsible: Resident Care Director, Maintenance Director, Concierge