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: Jan. 16, 2024 and Jan. 18, 2024

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: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 01/16/24 at 08:10 am to 03:50 pm and 01/18/24 at 08:11 am to 1:20 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: 62 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: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: A medication pass observation was completed for three residents. Breakfast, lunch, and an activity were observed. 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 #:	22VAC40-73-290-B
Description:	Based on onsite observation the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge. Evidence: 1. During observation of the facility on 01/16/24 at 8:10 am, the facility?s manager on duty posting listed staff #5 and staff #6 as the manager on duty. Staff #5 and staff #6 was not onsite in the building at 8:10 am. Staff #7 confirmed that staff #5 and staff #7 was not onsite in the building at 8:10 am. 2. During observation on 01/16/24 at 8:10 am, the facility?s shift supervisor posting included the date for 01/15/24 and did not include a listing of the shift supervisor on duty for 01/16/24.
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
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 a sex offender screening for resident #1.
Plan of Correction:	What Has Been Done to Correct? The Sex Offender Registry was run with the resident first name and her husband?s first name as her last name. A new registry was run with the corrected name and file updated. How Will Recurrence Be Prevented? Prior to physical move-in, Sex Offender Search will be completed. For the next 60 days, starting 2/05/24, the Executive Director/designee will review new admissions to assure this has been completed prior to physical move-in. Person Responsible: Business Office Manager
Standard #:	22VAC40-73-450-C
Description:	Based on the record review the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission and shall include the following: Description of identified needs based upon other sources. Evidence: 1. The record for resident #1 contains a physician order dated 08/14/23 that documents to change diet to No added Salt (NAS) Mechanical Soft. The facility?s dietary oversight dated 10/30/23 includes a recommendation for a NAS, diet order. Resident?s #1 ISP dated 12/15/23 documents the resident?s diet as ?regular diet? and does not include the resident?s dietary needs to include a NAS, and mechanical soft diet.
Plan of Correction:	What Has Been Done to Correct? Updated to reflect assessed need. How Will Recurrence Be Prevented? The Resident Care Director or designee will ensure that all resident ISPs will be updated at time of change in condition. The ISPs of all other residents were reviewed to ensure compliance 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 ISP in conjunction with resident, family, and/or caregivers while using the History and Physical, physician orders, UAI, and other support to ensure the individual 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 ISP and complete random monthly audit of a minimum of 5 ISPs to ensure ongoing compliance. Person Responsible: Resident Care Director
Standard #:	22VAC40-73-680-D
Description:	Based on the record review the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. The record for resident #3 contains a physician order dated 07/06/23 for Atenolol ?take one tablet by mouth every morning hold if systolic is less than 130 or if heart rate is less than 60.? Resident?s #3 Dec. Medication administration record (MAR) documents the resident was administered Atenolol on the following dates when the resident?s systolic was documented as being less than 130 and when the resident?s heart rate was documented as less than 60: 12/10/23, Systolic (117); 12/11/23, Systolic (124), heart rate (56); 12/13/23, Systolic (127); 12/14/23, Systolic (122); 12/18/23, Systolic (127); 12/23/23, Systolic (111); 12/31/23, Systolic (124).
Plan of Correction:	What Has Been Done to Correct? Prescriber and responsible party were contacted and there were no adverse effects How Will Recurrence Be Prevented? The Resident Care Director educated all nurses and RMAs on the requirements of following all physician orders. The Resident Care Director or Designee will review the MAR of a minimum of 5 residents daily to ensure ongoing compliance. Person Responsible: Resident Care Director
Standard #:	22VAC40-73-870-A
Description:	Based on observation the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. Evidence: 1. During an observation of the facility?s basement area, water was observed on the floor throughout the entire basement. Staff #5 reported an outside vendor assessed the water in the basement area on 01/03/24 as coming from a ?possible leak from a roof drain.?
Plan of Correction:	What Has Been Done to Correct? Water has been removed using wet vacuums. Will continue to monitor and remove any water until repaired. How Will Recurrence Be Prevented? General Contractor scheduled for 2/14/2024 to come onsite to verify area we identified is the location of the source of water. A formal plan for repair will be submitted and work done. Allowing for 90-days to plan and execute. Person Responsible: Maintenance Director
Standard #:	22VAC40-73-970-E
Description:	Based on the facility record review the facility failed to ensure a record of the required fire and emergency evacuation drills shall include: The method used for notification of the drill; number of staff and residents participating; any special conditions stimulated; the time it took to complete the drill; weather conditions; and problems encountered if any. Evidence: 1. The facility?s fire and emergency evacuations drills dated 10/20/23, 11/23/23, and 12/28/23 did not include the following documentation: The method used for notification of the drill; number of staff and residents participating; any special conditions stimulated; the time it took to complete the drill; weather conditions; and problems encountered if any.
Plan of Correction:	What Has Been Done to Correct? The record of required Fire and Emergency Evacuation drills was not completed, although drills were documented. Forms were printed the same day and set for use moving forward. The current Monthly drill will be taking place before 2/29/2024 How Will Recurrence Be Prevented? 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 #:	22VAC40-90-40-C
Description:	Based on the onsite record review the facility failed to ensure any person required to obtain a criminal history report shall be ineligible for employment if the report contains convictions of barrier crimes. Evidence: 1. Staff #8, hired 02/07/23, criminal record report contains two convictions for barrier crimes (18.2-57).
Plan of Correction:	What Has Been Done to Correct? Employee in question has been separated from employment. How Will Recurrence Be Prevented? Executive Director and Business Office Manager will review all employee records to ensure eligibility. Have two personnel review records moving forward when received for potential new hires. Person Responsible: Business Office Manager