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: May 18, 2023

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 ARTICLE 1 ? SUBJECTIVITY 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

Technical Assistance:

Ensure Criminal Record Checks include the correct spelling of the first and last name.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An announced renewal inspection took place on 05/18/2023 from 8:18 am to 4:00 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast, Lunch and an activity were observed. A medication pass observation was completed for five residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on the record review the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. The record for resident #6, contains a progress note dated 02/23/23 that documents ?resident came out of room with a raised bruise noted to her left eye.? The facility did not provide a report to the regional licensing office reporting the observation of the resident?s bruised eye on 02/23/23. 2. The record for resident #2, contains a progress noted dated 04/25/23 that documents ?resident sent out to ER due to shortness of breath.? A progress note dated 04/29/23 documents ?resident returned from hospital on hospice.? The facility did not provide a report to the regional licensing office reporting the resident?s hospital admission from 04/25/23-04/29/23. 3. The record for resident # 1 contains a medical note dated 05/05/23 that documents ?patient seen for follow-up due to recent hospitalization 04/27-05/01 due to pneumonia due to COVID 19.? The facility did not provide a report to the regional licensing office reporting the resident?s hospital admission from 04/27/23-05/01/23.
Plan of Correction:	Executive Director has informed management team as well as educated front line associates to inform management when any resident is sent out 911 whether for a fall or medical emergency. Executive Director or designee will submit within 24 hours to the LI a report of any resident leaving the community due to a fall or medical emergency.
Standard #:	22VAC40-73-310-H
Description:	Based on the record review the facility failed to ensure in accordance with 63.2-1808 of the Code of Virginia, assisted living facilities shall not admit or retain individuals with any of the following conditions or care needs: psychotropic medications without appropriate diagnosis and treatment plans. Evidence: 1. The record for resident #3 contains a physician order dated 05/02/23 to include ?Sertraline 25mg, take one tablet by mouth every day for depression.? The record does not contain documentation of a treatment plan for the psychotropic medication, Sertraline.
Plan of Correction:	Record for resident #3 has been updated to include Sertraline 25mg tablet daily for depression to residents current psychoactive medications and diagnosis sheet (see attached). An audit will be completed of current residents to assure psychotropic treatment plans are in place to address current psychoactive medications for each resident. This audit will be completed by 6/30/2023. The Pscyhotropic Treatment Plan for each psychoactive medication that a resident is currently prescribed will be obtained at move-in, with change in medication/dose, and reviewed for update at least every 6 months to assure medication is included with appropriate diagnosis and treatment plan. RCD or Designee
Standard #:	22VAC40-73-320-B
Description:	Based on the record review the facility failed to ensure a risk assessment for (TB) shall be completed annually on each resident as evidenced by completion of the current screening form published by the Virginia Department of Health or form consistent with it. Evidence: 1. The record for resident #2 contains a risk assessment for TB dated 09/22/21. The resident?s record does not contain an annual risk assessment for TB completed after 09/22/21.
Plan of Correction:	Risk assessment for Resident #1 has been completed and chart updated. (see attached). An audit of current residents will be conducted to assure updated TB risk assessment has been completed annually. This audit will be completed by 6/30/2023. Moving forward TB Risk assessments will be tracked by the RCD/designee and annual risk assessment will be completed per regulatory standards RCD or Designee
Standard #:	22VAC40-73-450-C
Description:	Based on the record review the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission and shall include a description of identified needs based upon the uniform assessment instrument (UAI). Evidence: 1. The record for resident # 3, admission date 02/21/23, contains an ISP dated 04/10/23. The ISP in the record is dated more than 30 days after the resident?s admission date. 2.Resident # 1?s UAI dated 04/30/23 documents mechanical and human help needed for transferring. The resident?s ISP dated 05/04/23 does not include documentation of the mechanical help needed for transferring. 3. Resident # 2?s UAI dated 04/29/23 documents mechanical help needed for toileting and transferring. The resident?s ISP dated 05/05/23 does not include documentation of the mechanical help needed for toileting and transferring. 4. Resident #3?s UAI dated 03/25/23 documents mechanical help needed for dressing, toileting, and transferring. The resident?s ISP dated 04/10/23 does not include documentation of the mechanical help needed for dressing, toileting, and transferring.
Plan of Correction:	RCD has reviewed UAl's and ISP's for residents #1,#2 and #3. Corrections have been made to the ISP to more accurately reflect the UAI and the assistance these residents need. RCD or designee will conduct random audits comparing UAI and ISP's to ensure they match. These will be conducted quarterly. First audit to be conducted in June 2023 RCD or designee will also ensure that there is a comprehensive ISP completed within 30 days of admission for each resident. RCD or Designee