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: Feb. 19, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced focused monitoring inspection was conducted on February 19, 2020 from 11:39 am until 5:10 pm in response to an incident report that was received. There were 69 residents in care. During the inspection, resident and staff records were reviewed. Residents and staff were interviewed. Video footage reviewed regarding a staff to resident altercation. Discussed available training for staff focusing on aggressive behaviors and residents with cognitive impairments. Also discussed the facility's abuse policy and resident rights. 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. Steps 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. The plan of correction is due within 10 calendar days from today, on 05-04-2020.

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on record review and interview, the facility failed to ensure the regional licensing office was notified of an incident that negatively affected or threatened the health, safety, or welfare of a resident. Evidence: 1. The facility did not notify the regional licensing office of two incidents involving resident #1 being physically aggressive towards resident?s #2 and #3. 2. Resident #1?s nursing notes documented: a. On 01-20-2020 resident #1 "smack[ed]" resident #2 in the face. b. On 02-03-2020 resident #1 "smack[ed]" resident #3 in the face. 3. Staff #1 acknowledged the incidents were not reported to regional licensing office within 24 hours.
Plan of Correction:	Executive Director, Resident Care Director, and Assistant Resident Care Director were re-inserviced on timely submission of initial notification of incidents and detailed incident reports to the Licensing Inspector in accordance with DSS Licensing Standards. The Executive Director, Resident Care Director, and Assistant Resident Care Director will review submitted incident reports daily to ensure compliance with timely submission of incident reports for continued compliance.
Standard #:	22VAC40-73-550-C
Description:	Based on record review and interview, the facility failed to ensure the resident is free from mental, emotional, and physical abuse by personnel of the facility as provided in ? 63.2-1808 of the Code of Virginia and this chapter. Evidence: 1. Video footage dated 02-11-2020 was reviewed by two Licensing Representatives and staff #1, regarding an incident with resident #1 and staff #4, the following was observed: At approximately 7:40 pm resident #1 was standing in the doorway of resident #4's room. Staff #4 was standing in the intersection of the hallway near the water cart next to the nurses' station, facing resident #1. Staff #4 was speaking to the resident. At approximately 7:42 pm resident #1 walked back up the hallway in the direction of the staff #4. Resident #1 stopped by the water cart and was observed speaking to staff #4. Staff #4?s hand was observed swinging in an upward motion. Resident #1 and staff #4 were swinging closed fists at each other and making contact. Staff #4 pushed resident #1 two times and the resident fell backwards to the floor. Resident #1?s head hit the wall. 2. Staff #1 stated EMS transported resident #1 via ambulance to the local emergency room. 3. A hospital discharge note dated 02-11-2020 documented resident #1 sustained a head injury requiring staples to the back of the head, as well as a skin tear to the right upper arm. Staff #2 stated the resident returned to the facility with 6 staples to the back of the head. 4. Staff #4's "Counseling/Disciplinary Notice" dated 2-17-2020, documented the staff was terminated for ?committing... physical, verbal or mental abuse of resident either by act or omission? and ?additional violation of resident rights?. 5. Staff #1 provided a copy of the facility?s Resident Rights policy labeled ?GP11 - Resident Rights (02/01/2019).? The policy documented ?Staff will observe and respect the personal rights of all residents residing in the Community? Any resident of an assisted living facility has the rights and responsibilities enumerated in this section. The operator or administrator of an assisted living facility shall? ensure that, at the minimum, each person who becomes a resident of the assisted living facility? Is free from mental, emotional, physical, sexual, and economic abuse or exploitation; is free from forced isolation, threats or other degrading or demeaning acts against him; and his known needs are not neglected or ignored by personnel of the facility??
Plan of Correction:	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. Staff #4 was suspended and then terminated. DSS, APS and Norfolk Police were both notified at the time of the event. 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.
Standard #:	22VAC40-73-660-A
Description:	Based on observation and interview, the facility failed to ensure medications are stored in a medicine cabinet, container, or compartment. Evidence: 1. A Zoloft 25mg tablet was observed in a bubble package laying on top of the medication cart. The medication cart was unattended and unsupervised in the hallway across from the activity room. Staff #3 was observed exiting the activity room. 2. Staff #3 was assigned to the medication cart. Staff #3 stated she was cleaning out the medication cart and acknowledged the bubble package of Zoloft 25mg was unattended and was not stored in the medication cart.
Plan of Correction:	Medication was removed to secured location. Employee was re-educated on the safety and security of medications. Resident Care Director reeducated all RMA?s on securing medication to ensure resident safety and compliance with DSS Standards. Executive Director, Resident Care Director, or designee will complete random checks to ensure continued compliance.