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: July 2, 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

Technical Assistance:

Personal Data Form

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 07/02/2024 at 09:25 am to 11:25 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self- reported incident was received by VDSS Division of Licensing on 6/07/2024 regarding allegations in the area of: Resident Care and Related Services and the Safe Secure Environment. Number of residents present at the facility at the beginning of the inspection: 66 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: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation of the safe secure environment was completed. A review of the facility?s practice plan for resident emergencies was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-1150-A
Description:	Based on the record review and staff interview the facility failed to ensure doors that lead to unprotected areas shall be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates. Residents who reside in safe, secure environments may be prohibited from exiting the facility or the special care unit if applicable building and fire codes are met. Evidence: 1. Resident?s #1 incident reports for ?resident elopement? dated 6/07/24 and 6/14/24 documents the following: ?sweet memories (facility?s safe secure unit) courtyard gate left unlocked by community?s landscaping company;? ?resident breached the secured gate;? ?resident found walking on the sidewalk by the community.? 2. The record for resident #1 contains a progress note dated 6/07/24 that documents the following: ?lawn care workers left the back gate open and resident walked out of the gate and walked across the street.? 3.During an interview with staff #1, staff #1 reported that resident #1 left the safe secure unit?s courtyard through an unlocked gate located outside. Staff #1 reported the courtyard gate was left unlocked by the community?s landscaping company. 4. During observation with staff #2, the secured gate located outside of the safe secure unit?s courtyard was observed to lead to a sidewalk area that is not protected or secured by the facility. Staff #2 confirmed the secured gate observed was the gate left unlocked and the gate resident #1 exited during the elopement incident on 06/07/24.
Plan of Correction:	What Has Been Done to Correct? Staff inspect doors, gates, exits, and secure outdoor areas at shift changes. Staff inspect doors, gates, exits, and secure outdoor area once resident?s go out into area. Landscaping company notified of updated process/procedure put in place moving forward. How Will Recurrence Be Prevented? Inspection of doors, gates, exits, and secure outdoor areas ensures that the area is secured and safe for the residents. Increased frequency of checks ensures no changes in the status or condition of the area and opportunity to address any issues that do arise. Landscaping to continue to gain access to secured area only by staff escort. Staff will close and secure the door behind the landscaping employee. The employee will be granted access to exit by community staff; door to be closed and secured by staff each time, not left open at any time. Person Responsible: Clinical Department; RCD; ED
Standard #:	22VAC40-73-460-D
Description:	Based on the onsite staff interview and the record review the facility failed to provide supervision of resident schedules, care, and activities including attention to specialized needs, such as prevention of falls and wandering from the premises. Evidence: 1. Resident?s #1 incident reports dated 6/07/24 and 6/14/24 documents the following ?resident elopement? that occurred on 06/07/14: ?sweet memories (facility?s safe secure environment) courtyard gate left unlocked by community?s landscaping company;? ?resident breached the secured gate;? ? resident found walking on the sidewalk by the community;? ?resident out 30 minutes or less.? 2. The record for resident #1 contains a progress note dated 6/07/24 that documents the following: ?lawn care workers left the back gate open and resident walked out of the gate and walked across the street.? 3. During an interview with staff #1, staff #1 reported that resident #1 left the safe secure unit?s outside courtyard through an unlocked gate. Staff #1 reported resident #1 was on the sidewalk across the street from the facility when located by the facility staff. 4. The record for resident #1 contains an approval for placement in the safe secure unit dated 03/19/19 and a review for appropriateness of placement in the safe secure unit dated 05/05/24. 5. The record for resident #1 contains a uniform assessment instrument (UAI) dated 5/04/24 and an individualized service plan (ISP) dated 5/04/24 that documents a behavior pattern of wandering. 6. The record for resident #1 contains a physician order dated 07/06/23 and a physician note dated 05/09/24 that documents a diagnosis of Dementia.
Plan of Correction:	What Has Been Done to Correct? Times between rounds decreased for residents that are outdoors in secure area; increased rounding for resident?s that want to be in secured courtyard area. 30-minute rounds. How Will Recurrence Be Prevented? Increased frequency of rounds will allow for more supervision of residents, more opportunities to assess and attend to resident?s needs, and increased opportunity to redirect if needed. Increased staff rounding for resident?s outdoors will allow for more opportunities to ensure resident?s safety. Person Responsible: Clinical Department; RCD; ED