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: Oct. 3, 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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

Activity Calendar

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 10/03/2023 at 09:07 am to 11:18 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 09/06/2023 regarding allegations in the area(s) of: Personnel Number of residents present at the facility at the beginning of the inspection: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: An activity was observed in the safe secure environment and the assisted living unit. Resident?s and the common area bathrooms were observed. 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 #:	22VAC40-73-110-1
Description:	Based on staff interview and the resident record review the facility failed to ensure all staff be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirmed, or disabled. Evidence: 1. The record for resident #1 contains an incident report dated 09/08/23 documenting ?staff #2 reported resident #1 was prevented from going to the restroom of resident #1?s choice and time of choice by staff #1. Resident #1 was admonished verbally and made to wait to use the restroom. Staff #2 was separated from employment, findings did show neglect.? 2. During an interview with staff #2, staff #2 reported ?hearing resident #1 request assistance from staff #1 to use the bathroom located in the facility?s common area, staff #1 informed resident #1 to ?urinate in resident #1?s diaper and staff #1 refused to provide assistance to the resident to use the bathroom located in the facility?s common area.?
Plan of Correction:	What Has Been Done to Correct? As we Self-reported the issue, we immediately took steps to address the concerns. We separated employment with the associate in question. We provided Abuse and Neglect retraining to all staff. How Will Recurrence Be Prevented? Resident Care Director/designee and Executive Director/designee will review continue with regular training and reinforce the Resident Rights. Person Responsible: Executive Director
Standard #:	22VAC40-73-290-B
Description:	Based on observation the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge. Evidence: 1. Upon arrival at the facility on 10/03/2023 at 9:07 a.m. the Licensing Inspector (LI) observed a posting dated 10/07 and 10/08 that listed the ?manager on duty? as staff #6. A posting dated 10/04 listed staff #5 as the ?1'' shift supervisor?. Staff #5 and Staff #6 was not on site at the facility at the time of the LI arrival at the facility. 2. Staff #4 acknowledged being the onsite person in charge, however there was no posting to include the name of staff #4 as the on-site person in charge and no posting identifying the on-site person in charge for the date of 10/03/2023.
Plan of Correction:	What Has Been Done to Correct? The Concierge did not immediately update the on-site schedule when a change was identified. On-site Person-in-charge schedule was updated at time of issue How Will Recurrence Be Prevented? The Business Office Manager is responsible for ensuring the staff have the current listings. Daily, the Business office Manager/designee will review the listing to assure listing is kept current and up to date. Person Responsible: Business Office Manager