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. 7, 2023 and Feb. 8, 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 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 22VAC40-80 THE LICENSING PROCESS

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 02/07/23 at 08:45am to 03:25pm and 02/08/23 at 09:03 am to 1:30 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: 57 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: 6 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. A medication pass observation was completed for three residents. The following were reviewed: staffing schedule, emergency preparedness drills, medication carts, fire inspection report, and a health inspection report. 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 #1, contains progress notes documenting a hospital admission the dates of 12/13/22 through 01/24/23. 2. The record for resident # 3, contains progress notes documenting a hospital admission on the following dates: 01/24/23 through 01/27/23; 11/23/22 through 12/07/22; 12/08/22 through 01/10/23. 3. Staff # 7 acknowledged an incident report was not submitted to the regional licensing office to report the hospital admissions for residents #1, and # 3.
Plan of Correction:	We reviewed the Process for clarification with the Surveyor and are submitting notifications moving forward per regulation. Resident Care Director/designee and Executive Director/designee will review progress notes regularly to assure appropriate reporting occurs per regulatory standards. Person Responsible: Executive Director
Standard #:	22VAC40-73-250-D
Description:	The facility failed to ensure each staff person required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) in a communicable form as evidence by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. The record for staff # 3, contains documentation of a TB risk assessment completed 12/17/19. There is no documentation of an annual TB risk assessment completed after 12/17/19. 2. The record for staff #4, contains documentation of a TB risk assessment completed 07/03/21. There is no documentation of an annual TB risk assessment completed after 07/03/21.
Plan of Correction:	TB screens were done immediately (2/8/23) on associates with missing screenings. TB Assessments will be tracked and monitored for annual update by the Business Office Manager. For the next 60 days, starting 2/22/23, the Executive Director/designee will complete random audits of employee files to assure compliance. Person Responsible: Business Office Manager
Standard #:	22VAC40-73-260-C
Description:	Based on observation and staff interview the facility failed to ensure a listing of all staff who have current certification in first aid or CPR, in conformance with subsections A and B of this section, shall be posted in the facility so that the information is readily available to all staff at all times. Evidence: 1. During observation of the facility on 02/07/23 and 02/08/23 the listing of staff certified in First Aid or CPR was not posted in the facility. 2. Staff #2 and staff #7 acknowledged the listing of staff certified in First
Plan of Correction:	The Ballentine had a new Business Office Manager who did not have an updated listing. BOM has created a listing from reviewing associate records. Listing has been placed in Employee areas. Business Office Manager has a tickler file to ensure certifications remain up to date. Monthly, the Executive Director/designee will review the listing to assure listing is kept current and up to date. Person Responsible: Business Office Manager
Standard #:	22VAC40-73-310-D
Description:	Based on the record review the facility failed to ensure based upon review of the UAI prior to admission of a resident, the assisted living facility administrator provided written assurance to the resident that the facility has the appropriate license to meet his/her care needs at the time of admission. Evidence: 1. The record for resident #7, did not contain documentation of a written assurance provided to the resident.
Plan of Correction:	Updated Written Assurance signed by resident During lease signing process, Written Assurance will be signed and provided to the resident/responsible party. For 60 days, starting 2/22/23, the Executive Director/designee will review new admission paperwork to assure Written Assurance has been signed. Person Responsible: Executive Director
Standard #:	22VAC40-73-350-B
Description:	Based on the record review the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater three days or in fact stays longer than three days and shall document in the resident?s record that this was ascertained and the date the information was ascertained. Evidence: 1. The record for resident # 1, did not contain documentation of a completed sex offender screening.
Plan of Correction:	Sex Offender Registration search has been completed on Resident #1 and documentation added to resident file. Prior to physical move-in, Sex Offender Search will be completed. For the next 60 days, starting 2/22/23, the Executive Director/designee will review new admissions to assure this has been completed prior to physical move-in. Person Responsible: Executive Director
Standard #:	22VAC40-73-430-H-1
Description:	Based on the record review the facility failed to ensure at the time of discharge, the assisted living facility shall provide to the resident, and as appropriate, his legal guardian and designated contact person a dated statement signed by the licensee or administrator that contains the following statement: the actions taken by the facility to assist the resident in discharge and relocation process. Evidence: Resident?s #4, discharge statement dated 12/13/22 did not include documentation of the actions taken by the facility to assist the resident in discharge and relocation process.
Plan of Correction:	Documented was annotated with N/A as no assistance was needed. Executive Director/designee will assure that each area of the Discharge Notification has been appropriately addressed. Person Responsible: Executive Director
Standard #:	22VAC40-73-970-A
Description:	Based on the onsite review the facility failed to ensure fire and emergency drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills requested for each shift in a quarter shall not be conducted in the same month. Evidence: 1. The facility provided evidence of a fire and emergency evacuation drill dated 11/29/22. There was no evidence of the facility conducting fire and emergency evacuation drills on each shift at least quarterly. 2. Staff # 2 acknowledged the facility did not have documentation of fire and emergency evacuation drills being conducted on each shift at least quarterly.
Plan of Correction:	With Departure of the Maintenance Director the December and January drill documentation could not be located. The current Monthly drill will be taking place before 2/28/2023 Documentation for drills will be maintained by the Maintenance Director and a copy of drill documentation will be provided to the Executive Director/designee to place in Survey Binder. Person Responsible: Maintenance Director
Standard #:	22VAC40-73-990-C
Description:	Based on the onsite review the facility failed to ensure at least every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years. Evidence: 1. The facility provided documentation the facility participated in an exercise in which the procedures for resident emergencies were practiced on 12/12/22 and 01/24/23. The facility did not provide documentation of a practice of resident emergencies every six months during the year of 2022. 2. Staff #2 acknowledged there is no evidence of documentation within the last year of the facility practicing procedures for resident emergencies every 6 months.
Plan of Correction:	With the departure of the Maintenance Director the previous training documentation could not be located. Next training will be provided prior to 7/1/2023 and documentation of training will be maintained by the Maintenance Director and a copy will be provided to the Executive Director/designee for the Survey Binder. Person Responsible: Maintenance Director