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: April 20, 2021 , April 21, 2021 , April 22, 2021 and April 23, 2021

Complaint Related: Yes

Areas Reviewed:

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 April 20, 2021 and concluded on April 23, 2021. A complaint was received by the department regarding allegations in the areas of resident care and related services. 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. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and a violation was issued. The complaint is valid.

Violations:

Standard #:	22VAC40-73-460-B
Complaint related:	Yes
Description:	Based on record review and discussion, the facility failed to ensure prompt response by staff to resident needs. Evidence: 1. Resident #1?s call bell log documented the call bell activated a call on 02/04/2021 at 1:12 p.m. and staff response time was approximately 31 minutes later at 1:43 p.m. 2. Facility incident report received on 02/04/2021 documented Resident #1?s incident that occurred on 02/04/2021 at 2:00 p.m., ?RCD [Resident Care Director] was making rounds and observed resident [#1] on the floor in [resident #1?s] room. Hematoma noted to the back of [resident #1?s] head.? Subsequently, Resident #1 required medical attention and was hospitalized for two days. 3. The facility?s call bell logs documented staff response times ranged from approximately 10 minutes to approximately 573 minutes during January 2021 and February 2021. 4. Residents indicated that staff are taking ?more than 25 minutes to respond to calls for assistance to include toileting, bathing and response to falls?. 5. Staff #1 and Staff #2 confirmed during interview that the call bell logs showed varied lengths of times and did not report issues with the functionality of the call bell system.
Plan of Correction:	What Has Been Done to Correct? Nursing staff has been in-serviced on the integral part a call bell is to the life-safety of Residents. Medication Aides are to assist in answering call bells if they see excessive duration of a particular bell. Resident Care Associates will ensure they reset each call bell station and pendant after responding. How Will Recurrence Be Prevented? Call bells will be pulled randomly by Directors and response time noted. Disciplinary actions will be issued if not favorable. Any pulls that do not register accordingly will be reported to the vendor for resolution. Person Responsible: All Directors