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: June 22, 2022 and June 23, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS

Comments:

An unannounced renewal inspection was initiated and completed on 6/30/22- from 9:00 a.m. until 4:11p.m. The Acknowledgement of Inspection form was signed and left at the facility for this date of the inspection. Number of residents present at the facility at the beginning of the inspection: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 9 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication pass, dinning, water temperatures, bathrooms, resident?s apartments, kitchen, emergency food and water supply Additional Comments/Discussion: Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.

Violations:

Standard #:	22VAC40-73-1100-A
Description:	Based on record review, prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnoses of dementia in a safe, secure environment. Evidence 1. Resident #3 was admitted to the facility?s safe secure environment on 5/16/22; however, there is no documentation of approval for placement in the special care unit.
Plan of Correction:	The resident Approval for Placement document was obtained on July 19th and placed into their healthcare record. Going forward the RCD and/or Designee will ensure that the form is completed be the Responsible Party and updated in the records no later than the date of admission to the Memory Care neighborhood. Memory Care Resident Charts to be Audited for this document by August 8th.
Standard #:	22VAC40-73-250-C
Description:	Based on record review and discussion, the facility failed to maintain personal and social data on staff to include verification that the staff person has received a copy of his current job description. Evidence: 1. The records for Staff #4 and Staff #5 did not include verification that the staff person has received a copy of their current job description
Plan of Correction:	The two staff members have received their respective Job Descriptions and documentation is in their employee files. Going forward the BOM and/or Designee will ensure that each new hired employee and/or promoted employee receives a copy of their Job Description and that it is documented in their employee file. Auditing of Employee files to be completed by August 8th to ensure compliance.
Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of health or a form consistent with it. Evidence: 1. During onsite inspection on 6/23/22 and 6/23/22, there were no documentation of an initial tuberculosis examination and report for Staff #4 (DOH: 3/14/22).
Plan of Correction:	The staff member is no longer employed at the community. Going forward the BOM and/or Designee will ensure that each new hire has had the Screening form completed before hiring and also completed annually for each employee. Employee files will be Audited by August 8th for the Screening record.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure each direct care staff member maintained current certification in first aid from the American Red Cross, American Heart Association, national Safety Council, American safety and Health Institute, community college, hospital volunteer rescue squad, or fire department. Evidence: 1. Staff #4 and Staff #5 work as direct care staff and do not have a current certification in first aid
Plan of Correction:	The 2 staff members have completed their 1st Aid/CPR trainings and the community has documentation of as such in their employee file. Going forward the BOM and/or Designee will review All Employee Certifications on a Monthly basis to ensure compliance. Auditing of Employee files to be completed by August 8th to ensure compliance.
Standard #:	22VAC40-73-290-A
Description:	Based on observation and discussion, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge in a place in the facility. Evidence : During on-site inspection of the facility there was no posting of the current on-site person in charge in a place in the facility that was conspicuous to the residents. 1. Staff#8 acknowledged the on-site person in charge was not posted.
Plan of Correction:	The Daily Supervisor In-charge has been posted in the community and will be keep and updated Daily going forward. The Concierge and/or Designee will ensure it is updated daily. This is Completed.
Standard #:	22VAC40-73-310-D
Description:	Based on record review and interview, the facility failed to provide written assurance to the resident or legal representative documenting that the facility has the appropriate license to meet their care needs. Evidence: 1. Resident #3 did not have a copy of a written assurance in their record during record review. 2. Staff #3 acknowledged the aforementioned residents did not have a signed written assurance in the record at the time of inspection.
Plan of Correction:	The resident Letter of Assurance was completed on July 19th and placed into their Business Office Chart. Going forward the RCD and/or BOM and/or Designee will ensure that this document is reviewed and signed by the Responsible Party prior to Admission. Resident Charts to be Audited for this document by August 8th.
Standard #:	22VAC40-73-325-A
Description:	Based on record review and interview, the facility failed to ensure for residents who meet the criteria for assisted living care, by the time the comprehensive ISP is completed, a written fall risk rating be completed. Evidence: 1. Resident #1 and resident #2 meet the criteria for assisted living care and did not have a written fall risk rating completed. 2. Staff #3 acknowledged the aforementioned residents meet the criteria for assisted living care and did not have a written fall risk rating.
Plan of Correction:	Fall Risk Assessments were located for the two residents within our EHR system, as they were completed prior to move in. Going forward the Resident Care Director (RCD) and/or Designee will ensure Fall Assessment is printed and placed in the resident chart each time a residents (current/new) ISP is completed when due. All resident charts will be Audited by August 8th to ensure future compliance.
Standard #:	22VAC40-73-440-A
Description:	Based on review records the facility failed to ensure that the Uniform Assessment Instrument (UAI) prior to admissions. Evidence: The record for resident #3 did not contain documentation of a completed uniform assessment instrument prior to admission.
Plan of Correction:	The resident?s Initial UAI was completed prior to move in and was located within our EHR system and placed in her chart. Going forward the RCD and/or Designee will complete the UAI before admission and ensure it is placed in the chart, as well as the EHR. This will also be done for each resident on a yearly and/or ?as needed? basis. Resident Charts will be Audited to ensure printed copy is in each chart to be done by August 8th.
Standard #:	22VAC40-73-450-E
Description:	Based upon record review, the facility failed to ensure that the individualized service plan be signed by the licensee, administrator, or his designee, (i.e., the person who has developed the plan) and by the resident. Evidence: 1. The most recent individualized service plan for Resident # 2 and Resident #3 was not signed by Resident or Resident?s Legal Representative. .
Plan of Correction:	The RCD will set of a Date & Time to meet with and review ISP with the Responsible Party and/or obtain Signatures. Going forward the RCD and/or Designee will obtain the Resident and/or Responsible Party signature on the ISP when it has been updated and/or completed. Resident Charts to be Audited for this document by August 8th.
Standard #:	22VAC40-73-490-A-2
Description:	Based upon review the facility failed to employ a licensed health care professional who is onsite on full-time basis, a licensed health care professional, practicing within the scope of his profession to ensure that health care oversight is provided at least every six months, or often as indicated, based on his professional judgement of the seriousness of a resident?s needs or stability of a residents condition. Evidence: 1. The facility?s last health care oversite was dated on 12/3/21.
Plan of Correction:	The Community completed their bi-annual Healthcare Oversight on July 21st. Going forward the RCD and/or Designee will ensure that it is competed bi-annually during the 7th month of the year (July) and the 1st month of the year (January).
Standard #:	22VAC40-73-870-A
Description:	Based on observation, the facility failed to ensure the interior and exterior of all buildings be maintained in good repair and kept clean and free of rubbish. Evidence: 1. During a tour of the facility on 6-22-2022, the vents in the halls had a black and grey substance on them.
Plan of Correction:	The HVAC vents have been dusted (Completed) and going forward the Maintenance Director and/or Designee will monitor vents on his weekly Interior/Exterior Preventative Maintenance & Housekeeping schedule, as well as maintain a schedule for vents to be cleaned.
Standard #:	22VAC40-73-950-F
Description:	Based on record review and discussion, the facility failed to review the emergency preparedness plan annually or more often as needed, document the review by signing and dating the plan, and make necessary plan revisions. Evidence 1. Staff #8 was unable to provide verification that the emergency preparedness plan was reviewed annually.
Plan of Correction:	The Maintenance Director and/or Business Office Director and/or Designee will ensure that All Staff Members have had the Emergency Preparedness Plan reviewed with them on a yearly basis. All Staff will be in-serviced and completed by August 8th.
Standard #:	22VAC40-73-950-F
Description:	Based on record review and discussion, the facility failed to review the emergency preparedness plan annually or more often as needed, document the review by signing and dating the plan, and make necessary plan revisions. Evidence 1. Staff #8 was unable to provide verification that the emergency preparedness plan was reviewed annually.
Plan of Correction:	The Maintenance Director and/or Business Office Director and/or Designee will ensure that All Staff Members have had the Emergency Preparedness Plan reviewed with them on a yearly basis. All Staff will be in-serviced and completed by August 8th.
Standard #:	22VAC40-90-30-B
Description:	Based on record review, the facility failed to ensure the sworn statement or affirmation be completed for all applicants for employment. Evidence: 1. Staff #9 did not have a completed sworn statement in the record.
Plan of Correction:	The Sworn Disclosure was completed for this Employee. Going forward the Business Office Manager (BOM) and/or Designee will complete prior to any new Employee being hired at the community and/or when required for an existing Employee. Employee Records will be Audited by August 8th to ensure compliance.