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. 15, 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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 63.2 General Provisions. 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:

An unannounced renewal inspection was conducted by a Licensing Inspector and a Licensing Administrator on 02/15/2022 from 10:09 AM to 3:45 PM and on 02/17/2022 from 9:05 AM to 11:45 AM. There were 50 residents in care at the time of the inspection. A tour of the facility was conducted, water temperatures were sampled, and an activity and lunch were observed. Several medication passes were observed and staff and resident files were reviewed. Please complete your ?Plan of Correction? and ?Date to be Corrected? for each violation cited on the violation notice and return to me within 10 calendar days. If you have any questions, please contact your inspector.

Violations:

Standard #:	22VAC40-73-870-A
Description:	Based on observation and staff interviews, the facility failed to ensure the interior of the building was maintained in good repair and kept clean and free of rubbish. Evidence: 1. The smoke detector in the Sweet Memories Solarium was missing and wires were exposed. 2. Light bulb was out in the hallway in Sweet Memories unit. 3. There was a dresser with missing knobs and a broken drawer in the hallway. 4. There was a gap in between the French doors (rear service door by clinic) and the French doors directly across (front service doors). 5. Staff #1 acknowledged during onsite inspection interview the aforementioned areas were not in good repair nor kept free of rubbish.
Plan of Correction:	The smoke detector was replaced on 2/18/22. The light bulb was repaired on 3/15/22 by Relay electric. The dresser was removed from the community on 2.18.22 and the weather stripping was secured to both service French doors on 2/16/22. Maintenance director to monitor the community for all maintenance needs at the community and repair.
Standard #:	22VAC40-73-940-A
Description:	Based on an inspection at the facility on 2/15/22, the facility failed to obtain at least an annual fire inspection report by the appropriate fire official. Evidence: The last fire inspection for the facility was dated March 17, 2020.
Plan of Correction:	Fire Marshal was out on 2/21/22 to conduct the annual fire inspection. A few items needed to be corrected. Final inspection will be on 2/26/22. Maintenance Director will contact Fire Marshal annually to schedule annual inspection.
Standard #:	22VAC40-73-970-A
Description:	Based upon documentation and an interview, the facility failed to ensure fire drills were conducted on each shift for each quarter. Evidence: 1. On 2/15/22 a review of the facility?s fire drills documented for September 2021 through January 2022 did not include documentation of a drill being conducted on the 7am-3pm shift during the third quarter. 2. During onsite inspection Staff #1 acknowledged there was no documented fire drill for the 7am ? 3pm shift for the third quarter.
Plan of Correction:	The Ballentine was without an MD for almost 4 months. The new Maintenance Director has gotten the cadence back in order. The 7am-3pm fire drill was held March 17th, 2000. This will get us back in rhythm with the cadence for the quarterly drills. Maintenance Director is responsible for these drills. He now understands the cadence and the need to remain in compliance with the cadence to ensure we do not miss a required drill.
Standard #:	22VAC40-80-120-E-2
Description:	Based on observation and interview with facility staff on 2/15/22, the facility failed to post the findings of the most recent inspection report at the facility. Evidence: 1. The findings of the most recent inspection were not displayed; the date of the last inspection that was posted in the facility was 2/19/2020. The last inspection was conducted on March 16, 2021. 2. Staff #1 and Staff #2 confirmed during the inspection the most recent finding were not posted.
Plan of Correction:	Not available online. Contact Inspector for more information.