VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Georgian Manor
651 River Walk Parkway
Chesapeake, VA 23320
(757) 436-9618

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: May 21, 2024

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 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

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 unannounced renewal inspection took place on 05/21/2024 at 08:21 am until 02:45 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: 62 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: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Breakfast, lunch and an activity were observed. A medication pass observation was completed for three 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: 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 #:	22VAC40-73-450-H
Description:	Based on the onsite observation and record review the facility failed to ensure the facility shall ensure that the care and services specified in the individualized service plan (ISP) are provided to each resident. Evidence: 1. Resident?s # 3 ISP dated 12/31/23 includes the following: ?resident must be fed by mouth by another person.? Resident?s # 3 UAI dated 12/31/23 identifies the resident?s eating/feeding needs as performed by others, ?spoon fed.? During observation of breakfast in the safe, secure environment, resident #3 was observed to be eating independently without the assistance of another person.
Plan of Correction:	What Has Been Done to Correct? ISP has been updated to indicate that resident is now able to feed himself. How Will Recurrence Be Prevented? Changes will be made to care plan as significant changes occur with resident as report to RCD/ARCD by staff. Person Responsible: RCD and ARCD Due Date: Update to resident #3?s ISP was completed on 5/21/24 and POA was made aware of the change. POA was in on 5/30/24 and reviewed and signed off on the ISP. RCD and ED have also signed off.
Standard #:	22VAC40-73-640-A
Description:	Based on the record review, the facility failed to implement a written plan for medication management to include: a plan for proper disposal of medication. Evidence: 1. The facility?s medication management plan includes the following: ?all discontinued medication will be returned to the pharmacy or destroyed within 72 hours of discontinuance.? 2. The record for resident #2 contains a physician order dated 04/30/24 to discontinue the use of ?Trospium CL tab 20mg.? During the medication pass observation completed on 05/21/24, with staff #1, ? Trospium CL tab 20mg? for resident #2 was observed on the medication cart. Staff #6 confirmed Trospium for resident #2 was discontinued on 4/30/24 according to the resident?s physician order.
Plan of Correction:	What Has Been Done to Correct? The medication, Trospium CL 20mg, has been removed from the medication cart and destroyed by RCD on 5/21/24. How Will Recurrence Be Prevented? RCD/ARCD will conduct monthly med cart audits to ensure compliance with this standard. Person Responsible: RCD/ARCD
Standard #:	22VAC40-73-940-A
Description:	Based on the facility record review, the facility failed to ensure an assisted living facility shall comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: 1. The most recent fire inspection completed at the facility was dated 3/27/23.
Plan of Correction:	What Has Been Done to Correct? The Fire Marshall conducted the on-site fire inspection of the facility on 5/23/24. See attached Operational Fire Code Permit How Will Recurrence Be Prevented? Maintenance Director (MD) will ensure that the on-site fire inspection will occur prior to the expiration date of this license which is 5/22/25 by placing on his calendar as a reminder of this annual inspection. Person Responsible: Maintenance Director (MD)