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: Jan. 25, 2021 , Jan. 26, 2021 and Jan. 27, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 January 7, 2021 and concluded on January 27, 2021. A complaint was received by the department regarding allegations in the areas of Resident Care and Related Services, involving staff cell phone personal use and resident care being delayed. The Senior Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Senior Executive Director a list of documentation required to complete the investigation, as well as conducted staff interviews. The evidence gathered could not substantiate the allegation in the complaint; however, non-compliance with standards or law were cited, 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. Consultation provided regarding oral orders, staff documentation of assisting residents during COVID with calls, etc.

Violations:

Standard #:	22VAC40-73-300-B
Complaint related:	No
Description:	Based on record review and discussion, the facility did not maintain written communications f used for keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, for at least the past two years. Evidence: 1. Staff #1 and Staff #2 could not provide August and September 2020 nor January 2021 ?Shift to Shift? Notes. Staff #1 stated ?We don?t keep them past 30 days? and Staff #2 had stated ?We are no longer were documenting in between shifts.? Additionally, Staff #1 stated the facility uses oral communication during ?Standup? morning meetings. 2. Staff #1 and Staff #2 confirmed during discussion that the requested documents were not available and could not be provided for review.
Plan of Correction:	What Has Been Done to Correct? During each shift there is a log for Direct Care Staff to document in on each side of the Community, Assisted Living & Memory Care. At the end of the month, Resident Care Director stores the notes in a binder and it will be maintained in her office. How Will Recurrence Be Prevented? Resident Care Director and or Asst. Resident Care Director will initial the Direct Care logs daily. Person Responsible: Resident Care Director and or Asst. Resident Care Director.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to ensure Individualized service plans (ISPs) were reviewed and updated as needed as the condition of the resident changes. Evidence: 1. Resident #1?s ISP dated 11-10-2020 documented resident receives ?Human Help, Physical Assistance? with eating/feeding, and Uniform Assessment Instrument (UAI) dated 10-31-2020 documented resident receives ?Human Help, Supervision? with eating/feeding. Resident #1?s ISP did not document a service need for stairclimbing; however, the UAI documented resident requires ?Human Help, Physical Assistance? with stairclimbing. 2. Resident #2?s ISP dated 08-12-20 did not document a service for resident?s bowels; however, UAI dated 08-12-20 documented resident is ?Incontinent, Weekly or More? with bowels. 3. Staff #2 confirmed Resident #1 and Resident #2?s UAIs were correct; however, ISP services were not updated to reflect residents? changes.
Plan of Correction:	What Has Been Done to Correct? Cited Resident?s ISP?s have been updated to accurately reflect the information on the UAI?s. How Will Recurrence Be Prevented? Senior Executive Director & Resident Care Director will review together new residents and current residents care plans to ensure they are a mirror-image of the UAI?s. Person Responsible: Senior Executive Director & Resident Care Director.