VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at the Ballentine
7211 Granby Street
Norfolk, VA 23505
(757) 440-7400

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Sept. 25, 2019 and Sept. 26, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

This was an unannounced focused monitoring inspection conducted by the Licensing Inspector from the Eastern Regional Office with the assistance of a second inspector on the second day. The inspection was conducted on September 25, 2019 from 10:17 am until 5:33 pm and on September 26, 2019 from 11:17 am until 4:15 pm. During the inspection a tour of the memory care unit and courtyard was conducted, resident records and staff records were reviewed, and staff were interviewed. A discussion was held regarding the memory care courtyard doors and the new process to ensure the courtyard is secured. Also discussed resident falls as well as training for the staff person in charge. The facility received violations in the areas of Personnel and Resident Care and Related Services. The areas of noncompliance were discussed with the Executive Director throughout the inspection and during the exit interview. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice. The plan of correction must indicate how the violation will be or has been corrected. Your plan of correction should include: 1. Step(s) to correct the non-compliance with the standard(s) 2. Methods to prevent re-occurrence, and 3. Person(s) responsible for implementing each step and/or monitoring any preventive action(s).

Violations:

Standard #:	22VAC40-73-110-1
Description:	Based on observation and interview, the facility failed to ensure all staff were considerate and respectful of the rights, dignity and sensitivities of persons who are aged. Evidence: 1. On 9-25-19 during review of the facility?s video footage of the memory care dining room on 9-21-19 during the 3 pm- 11 pm shift, the following was observed: a. Resident #3 had an unwitnessed fall in the memory care dining room at approximately 7:10 pm. Staff #5 walked into the dining room approximately 2 minutes later, observed the resident on the floor and walked away without acknowledging the resident on the floor. Approximately one (1) minute later, staff #4 walked toward the resident, looked at the resident on the floor and walked away. Staff #6 was observed walking into the dining room towards the resident. Staff #6 looked at the resident on the floor and started to move the resident?s wheelchair and dining chairs surrounding the area where the resident was laying. The resident was observed on the floor attempting to sit up off the floor independently. Once the resident lifted her head off the floor a red circular stain that appeared to be blood was observed on the floor where her head had laid. Staff #7 arrived at 7:15 pm and was observed putting gloves on and appeared to assist the resident, approximately 3 minutes and 40 seconds after the resident was first found on the floor. b. Staff #4, #5, and #6 were not observed being sensitive to the resident or acknowledging the resident when observed on the floor. c. Per the resident?s ?Review of Appropriateness of Continued Residence in Special Care Unit? form dated 5-13-19, the resident needs continued placement in the special care unit (memory care) due to a ?primary diagnosis of dementia, resident exhibits poor safety judgement and poor self-awareness?.
Plan of Correction:	Associates were disciplined up to and including termination. Report made to DSS and APS as per DSS Licensing Standards and Mandated Reporting and the appropriate credentialing board. All associates were re-inserviced on Resident Rights and Mandated Reporting. Community will continue to screen applicants to include reference checks, credential verification, background checks, sworn disclosure, and other elements to hire and retain associates to provide for the health, safety, and well-being of all residents in accordance with DSS Licensing. Those found not to meet the requirements will not be hired nor retained. Those found to violate care expectations will be addressed by means of disciplinary action and mandated reported to APS and the appropriate credentialing board. The Executive Director, Resident Care Director, or designee will continue to monitor care provided and screen and retain high performance associates to ensure continued compliance.
Standard #:	22VAC40-73-190-C
Description:	Based on record review and interview, the facility failed to ensure prior to being placed in charge, a staff member was informed of and received training on their duties and responsibilities and provided written documentation of such duties and responsibilities. Evidence: 1. During review of staff written schedules, the schedule for Saturday 9-21-19 did not indicate the name of the staff person in charge. Licensing inspectors asked staff #2 who the staff person in charge was in the memory care unit on Saturday 9-21-2019 during the 3 pm-11 pm shift. Staff #2 stated that the RMAs assigned to the medication cart in each unit are in charge. Per the staff schedule, staff #4 was in charge in Sweet Memories (memory care unit) on the aforementioned date and shift. 2. During interview, staff #2 acknowledged staff #4 was the person in charge during the 3 pm-11 pm shift on 9-21-19. LI asked staff #1 and staff #2 for written documentation that staff #4 was informed of and received training regarding their duties and responsibilities as the person in charge. Staff #1 and staff #2 were not able to provide documentation to verify this training was provided and that staff #4 was informed of their duties prior to being in charge.
Plan of Correction:	Staff #4 was unable to be inserviced on her duties as a staff person in charge because she was immediately terminated. All RMAs and Licensed Nurses who have the ability to function as shift supervisor were oriented to the duties of the role. All resident care associates will be re-educated on the shift assignment sheet so that they are aware who is the staff person in charge. Executive Director, Business Office, or designee will audit the files of new hire RMAs to ensure that documentation of the orientation to the duties is competed and the files of Resident Care Associates will be audited to ensure orientation is provided on reading the posted schedule to see who the staff person in charge is for continued compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview, the facility failed to ensure the comprehensive individualized service plan (ISP) include a description of the resident?s identified needs. Evidence: 1. Resident #1 was admitted on 3-19-19. All admission paperwork was signed by the resident?s legal Guardian. 2. The resident had a Guardianship order in the record dated 2-28-19. Resident #1?s comprehensive ISP dated 4-22-19 did not include a description of the resident?s need for a Guardian, the name of the Guardian and/or public Guardian agency, or the contact information for the Guardian. 3. In addition, resident #1?s preliminary ISP dated 3-19-19 indicated the resident was an elopement risk, and indicated ?wandering? under ?disruptive behavior?. The comprehensive ISP did not include a description of the resident?s risk for elopement/wandering. The ISP was updated to include elopement on 9-18-19, after the resident wandered from the facility premises. 4. During interview, staff #2 acknowledged resident #1?s ISP did not include the resident?s need for a Guardian and risk of elopement until after the resident eloped.
Plan of Correction:	Resident #1ISP was updated to reflect residents current assessed needs. The Resident Care Director or designee will ensure that each ISP is reviewed and updated annually or if there is a change in the resident condition. The ISPs of other residents were reviewed to ensure compliance. Records reviewed to include identified need and what type of assistance staff are to provide to include coordinated services, basic needs identified, and signature of legal representative. Community will continue to complete Preliminary ISP and Comprehensive ISP in conjunction with resident, family, and/or caregivers while using the History and Physical, physician orders, UAI, and other support to ensure the individualized basic needs of the resident are adequately identified to include type of assistance needed to protect the resident?s health, safety, type of assistance required by coordinated services if applicable, and required signatures. Executive Director will review the Preliminary ISP on the date of admission. Executive Director or designee will complete random monthly audit of a minimum of 5 Comprehensive ISPs to ensure ongoing compliance.
Standard #:	22VAC40-73-460-D
Description:	Based on observation, record review and interview, the facility failed to provide supervision of resident schedules, care and activities including attention to specialized needs, such as prevention of falls and wandering from the premises. Evidence: 1. An incident report dated 9-19-19, stated that resident #1 ?left [the] property via open gate in memory care courtyard?. Per the incident report, the resident was observed missing at approximately 2:30 pm and found at approximately 2:55 [pm] on the ?adjacent property at Granby High School band area?. a. Review of resident?s record revealed resident #1 was admitted to the memory care unit on 3-19-19. The resident was documented to have a serious cognitive impairment, requiring placement in the secured memory care unit, per the Serious Cognitive Assessment form dated 3-19-19. b. A psychology consult note in the resident?s record dated 2-11-19, prior to admission, indicated the resident was found wandering outside. c. The resident?s Preliminary Individualized Service Plan (ISP) dated 3-19-19 documented ?wandering? under the section titled ?disruptive behavior? and indicated ?yes? under ?Elopement Risk?. d. Resident?s most recent Uniform Assessment Instrument (UAI) dated 4-19-19 documented ?wandering/passive-weekly or more? under the section ?behavior pattern?. e. Review of the facility?s 2 Hour Round Check document, revealed resident #2 was documented as ?LOA? at 2pm. During interview, staff #3 stated she did not fill out the form at 2 pm, but filled it out at approximately 2:30 upon ending her shift, at which time the resident was reported missing, therefore she documented ?LOA?. f. During interview, Staff #2 indicated the resident?s Guardian informed the facility of the resident?s risk of wandering at the time of admission. Staff #2 indicated that an outside contractor left the memory care gate open during service to the facility grounds. When asked if the facility was made aware that the gate was open, staff #1 indicated facility staff is made aware when the contractor is on the premises and is responsible for opening the gate. Staff #1 acknowledged facility staff were aware that the gate was opened to allow the contractor to provide service to the facility grounds. 2. During a tour of the memory care unit, resident #2 was observed with a brace on the left arm. a. Review of an incident report dated 9-23-19 revealed resident #2 had a fall on 9-21-19. Per interview with staff #2, the fall was on 9-18-19 not on 9-21-19. The fall was unwitnessed. b. An x-ray report in the resident?s record dated 9-23-19 documented the resident as having a ?nondisplaced fracture...? on the left wrist. c. Further review of the resident?s record, revealed the resident had an unwitnessed fall on 8-14-2019. Review of the emergency room visit documentation dated 8-14-19, indicated the resident obtained a closed sacrum fracture and a right wrist fracture. 3. During interview, staff #1 and staff #2 acknowledged resident #1?s wandering from the premises, and resident #2?s falls which caused the resident to sustain 3 fractures.
Plan of Correction:	The provider's response for the "plan of correction" was not received as of 12/23/2019 and will not appear on this violation notice.
Standard #:	22VAC40-73-550-C
Description:	Based on observation and interview, the facility failed to ensure a resident had the right to be free from mental, emotional, and physical abuse, the right to be free from forced isolation, and the right to be free of physical or mechanical restraint as provided in section 63.2-1808 of the Code of Virginia. Evidence: 1. On 9-25-19, during review of the facility?s video footage of resident #3?s fall which occurred on 9-21-19, with staff #1 and staff #2, the following was observed: a. On 9-21-19 staff wheeled resident #3 into the dining room at approximately 5:18 pm in her high-back wheelchair. Resident #3 was seated at a table positioned against the wall facing the dining room window. At approximately 5:51 pm staff escorted the last resident out of the dining room, leaving resident #3 at the dining table. Staff #4 was observed eating in the dining room at a different table. At approximately 6:15 pm, staff #4 walked towards the resident who was at the dining table and adjusted the resident?s chair close to the wall and table. Staff #4 was observed to be locking the resident?s wheelchair and then positioning the table and chair behind the resident directly onto the back of the resident's high-back wheelchair, wedging the resident in between the two tables. Staff #4 walked away from the resident and the resident was observed looking back and was observed shifting her body side to side in the wheelchair. Staff #4 was observed returning to the dining room, exiting the back door of the dining room, and returning to the dining room approximately 2 minutes later. Staff #4 was observed turning off the lights in the dining room and exiting the dining room. The resident remained in the dark in the dining room with the light turned off for approximately 16 minutes and was observed attempting to move the chairs around her. Staff #4 returned at approximately 6:34 pm and re-positioned the resident back against the wall, and pushed the table and chair closer to the back of the resident?s wheelchair. Staff #4 was observed leaving the dining room. The resident was observed attempting to stand from her wheelchair and after approximately 32 minutes later she stood up. After coming to a standing position, the resident was observed holding on to surrounding table and chairs. At approximately 7:10 pm the resident fell head first and hit her head landing on her left side. 2. Per a hospice visit note dated 9-22-19, the resident sustained a wound to the left side of her forehead. 3. On 9-26-19, the resident was observed to have facial bruising under both the left eye and right eye and under the chin on the left side. 4. Staff #1 identified staff #4 observed in the video footage and stated that the resident was sent out to the emergency room however no hospital discharge documentation was provided due to the resident being on hospice. Staff #1 acknowledged staff #4 failed to provide the rights to the resident as per ?63.2-1808 of the Code of Virginia.
Plan of Correction:	Associate (Staff #4) was terminated and DSS, APS, and the Board of Nursing were notified. All associates were re-inserviced on Resident Rights and Mandated Reporting. Community will continue to screen applicants to include reference checks, credential verification, background checks, sworn disclosure, and other elements to hire and retain associates to provide for the health, safety, and well-being of all residents in accordance with DSS Licensing. Those found not to meet the requirements will not be hired nor retained. Those found to violate care expectations will be addressed by means of disciplinary action and mandated reporting to APS and the appropriate credentialing board. Executive Director will in-service all associates on Resident Rights. The Executive Director, Resident Care Director, or designee will continue to monitor care provided and screen and retain high performance associates to ensure continued compliance.