VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Cedar Manor
1324 Cedar Road
Chesapeake, VA 23222
(757) 548-4192

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Dec. 21, 2021

Complaint Related: Yes

Areas Reviewed:

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

Comments:

A complaint investigation was initiated on 11/30/2021 and concluded on 1/25/2022. An unannounced inspection was conducted on 12/21/21 from 8:15 a.m. to 10:45 a.m. by a Licensing Inspector and a Licensing Administrator. A complaint was received by the department regarding allegations in the areas of staffing and supervision, resident care, and call bell systems. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued.

Violations:

Standard #:	22VAC40-73-870-E
Complaint related:	No
Description:	Based upon observation and staff interview the facility call bell system was not in good repair, condition or fully operational. Evidence: 1. During the physical plant inspection conducted on 12/21/21, Licensing Inspector pulled the call bell in Resident #1's room and there was no staff response. The call bell system was not operational. 2. Staff #1 was present during the inspection and acknowledged the call bell system was not fully operational. Staff #1 reported the facility had been working to repair the call bell system since the week after Thanksgiving.
Plan of Correction:	Nursing staff to be retrained on use of call bell system. Replacement devices to be ordered to match staffing ratio. IT to evaluate areas of connection in building to ensure proper function. Check Call bell system response time by physically checking weekly for 3 months to be preformed by Maintenance Director and nursing in tandem). 2 hour round sheets to be completed on all AL residents for 6 months.