Virginia DSS · Assisted Living Facility

Commonwealth Senior Living at the Ballentine

📍 7211 Granby Street, Norfolk, VA, 23505

ID 38776One Year licenseActive
13
Inspections
On record
12
With violations
Visits that cited something
1
Clean visits
Nothing cited
42
Violations cited
Individual findings
30
Standards cited
Distinct rules
1
Complaint visits
Prompted by a complaint

Commonwealth Senior Living at the Ballentine was inspected 13 times between February 10, 2021 and February 24, 2026 by the Virginia Department of Social Services. 12 of those visits ended with violations cited and 1 with none. Across that history VDSS cited 42 violations under 30 distinct standards. 1 inspection was prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 11 of these 13 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
03/04/2027
Administrator
Patrice Cherry
Licensing inspector
Donesia Peoples
Inspector phone
757 353-0430
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

13

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

February 24, 2026Inspection4 violations
Inspection dates
02/24/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date 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 02/24/2026 at 8:09 am to 3:10 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: 76 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: Observations by licensing inspector: Breakfast and lunch were observed. A medication pass observation was completed for three residents. The following were reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, pest control reports. and a staffing schedule. 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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
22VAC40-73-680-M
Based on observation and staff interview, the facility failed to ensure medications shall be properly stored at the facility.
Evidence
  1. During observation of the medication cart with staff #4, the Licensing Inspector (LI) observed the following medications not properly stored according to the pharmacy label instructions to keep the medication refrigerated: • Lorazepam for resident #7 • Lorazepam for resident #8 • Lorazepam for resident #9 • Lorazepam for resident #10
  2. During an interview on 02/24/26 with staff #4, staff #4 confirmed the Lorazepam for residents #7, #8, #9, #10 are labeled to keep refrigerated however the medication was not kept refrigerated.
Plan of correction
What Has Been Done to Correct? Resident #7, # 8, #9 and #10 lorazepam was discarded by Resident Care Director and Assistant Resident Care Director and re-ordered via Southern pharmacy and placed in locked fridge. Corrected during inspection. How Will Recurrence Be Prevented? Medication carts will be audited bi-weekly. Person Responsible: Resident Care Director and Assistant Resident Care Director
22VAC40-73-410-A
Based on the record review and staff interview the facility failed to ensure upon admission upon admission, the assisted living facility shall provide an orientation for new residents and their legal representatives, including mealtimes, and use of the call system. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record.
Evidence
  1. The record for resident #1, admission date of 5/30/25, contains documentation of an orientation dated as completed on 9/26/25.
  2. During an interview on 02/24/2026 with staff #6, staff #6 confirmed the orientation for resident #1 is dated as completed on 9/26/25, after the resident’s admission.
Plan of correction
What Has Been Done to Correct? Orientation was completed and signed by legal representative for the resident #1 on 9/26/25. Upon audit by Executive Director. How Will Recurrence Be Prevented? Orientations will be completed immediately upon admission and signed by residents or legal representative. Person Responsible: Executive Director, Business Office Manager and/or Designee
22VAC40-73-350-B
Based on the record review and staff interview the facility failed to ensure the facility shall 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 than 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 obtained.
Evidence
  1. The record for resident #1, admission date 5/30/25,contains a sex offender search dated as completed on8/19/25. 2.During an interview on 2/24/26 with staff #6, staff #6confirmed the sex offender search for resident #1 was completed on 8/19/25, after the resident’s admission.
Plan of correction
What Has Been Done to Correct? Upon audit of resident #1 business file, Executive Director corrected sex offender on 8/19/25 How Will Recurrence Be Prevented? Sex Offender will be completed and reviewed prior to all admissions Person Responsible: Executive Director, Business Office Manager and/or Designee
22VAC40-73-450-C
Based on the record review and staff interview the facility failed to ensure the comprehensive individualized service plan (ISP) shall include the following: Description of identified needs based upon the UAI, admission physical examination, and other sources.
Evidence
  1. The record for resident #1, admission date of 5/30/25, contains the following that documents the resident needs a mechanical soft diet: • An admission physical examination dated 5/30/25. • A dietary communication notification form dated 5/30/25. • A Physician order dated 01/09/26. Resident #1’s ISP dated 10/24/25 does not include the resident’s need for a mechanical soft diet and the ISP documents the resident’s diet as a regular diet.
  2. Resident #1’s UAI dated 10/24/25 documents the resident needs mechanical support with transferring. The resident’s ISP dated 10/24/25 does not include a mechanical support need for transferring and documents the resident does not require assistance with transferring.
  3. During an interview on 02/24/26 with staff #5, staff #5 confirmed resident #1’s ISP dated 10/24/25 does not include the resident’s need for a mechanical soft diet nor a mechanical support need for transferring.
Plan of correction
What Has Been Done to Correct? Resident #1 ISP dated 10/24/25 was updated to reflect mechanical soft diet. UAI for resident #1 dated 10/24/25 was updated to reflect chair arms as transferring device. Corrected during inspection. How Will Recurrence Be Prevented? Random UAI’s and ISP’s will be audited monthly Person Responsible: Resident Care Director and Assistant Resident Care Director
February 24, 2026Inspection0 violations
Inspection dates
02/24/2026
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date 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 02/24/2026 at 3:10 pm to 4:30 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 01/19/2026 regarding allegations in the area of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 76 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: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Resident were observed in the safe secure environment. Additional Comments/Discussion: None The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 11, 2025Inspection1 violation
Inspection dates
12/11/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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 12/11/2025 at 09:40 am to 12:15 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 11/03/2025 regarding allegations in the area of: Resident Care and Related Services. 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
22VAC40-73-450-H
Based on the record review and staff interview the facility failed to ensure that the care and services specified in the individualized service plan (ISP) are provided to each resident.
Evidence
  1. The record for resident #1, admission date 10/28/25, contains an ISP dated 10/28/25 that documents an allergy to seafood, need to monitor for allergies, and not to receive known allergy. 2.Resident #1’s incident report dated 11/01/25 documents the following: •Resident informed staff the resident needed something for allergy treatment because the resident had eaten fish for dinner. The resident was noted to be wheezing. •Resident has an allergy to seafood and was given fish at dinner when given a choice by staff. 3.During an interview on 12/11/25 with staff #3 and staff #5, staff #3 and staff #5 confirmed staff #1 provided resident #1 with a seafood meal that contained fish on 11/01/25.
  2. Resident #1’s emergency department hospital paperwork dated 11/01/25 documents the resident was evaluated for possible allergic reaction. The resident was prescribed Benadryl and Pepcid as needed for allergic symptoms.
Plan of correction
On 11/03/2025 Resident Care Director, Executive Director and Assistant Resident Care Director placed a copy of dietary summary in Sweet Memories dining room cabinet. All new hires are shown during orientation. On 11/12/2025 all existing staff were in-serviced on dietary summaries location and making sure you are handing out correct meal plates.
July 9, 2025Inspection2 violations
Inspection dates
07/09/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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 07/09/2025 at 09:55 am to 11:15 am. 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 6/21/2025 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: 71 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: 2 Observations by licensing inspector: An observation of the safe secure environment to include doors and windows was completed. A review of the facility’s staffing schedule 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
22VAC40-73-1150-A
Based on the record review, incident report review, email records, 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 #1’s incident report dated 06/26/2025 documents the following “elopement” that occurred on 06/21/2025 from the facility’s safe secure unit: “The Camera review showed resident pushing egress bar and exiting out of stairwell 2 door at 1:14 pm.”
  2. Staff #3 sent an email on 07/07/25 to the Licensing Inspector (LI) documenting that an alarm did not sound when resident #1 exited the safe secure unit though an exit door.
  3. During an interview on 07/09/25 with staff #1, staff #1 reported that on 06/21/25, resident #1 exited the safe secure unit through an exit door. Staff #1 confirmed the exit door was not secured with a lock, and the door alarm did not sound when the resident exited the door. 4.The record for resident #1 admitted to the facility’s safe secure unit on 06/19/25, contains an assessment for serious cognitive impairment that documents the resident has serious cognitive impairment due to a diagnosis of dementia and the resident is unable to recognize danger or protect his/her own safety.
  4. The record for resident #1 contains a physical exam dated 06/15/25 that documents a diagnosis of moderate dementia w/ anxiety.
Plan of correction
Stairwell 2 was inspected by Maintenance Director and determined to be working properly. Key alarm was not turned on. All registered medication aides were in-serviced on rounding on all alarmed doors at beginning of shift on secure unit for 30 days.
22VAC40-73-460-D
Based on the onsite staff interview, incident report review, 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 report dated 06/26/2025 documents the following “elopement” that occurred on 06/21/2025 from the facility’s safe secure unit: • “The Camera review showed resident pushing egress bar and exiting out of stairwell 2 door at 1:14 pm;” • Around 2:45 pm the facility received a call from the Norfolk fire department stating resident #1 was at Walgreens (115 West Little Creek Road, Norfolk, VA 23505) located a ½ mile from the facility.
  2. MapQuest directions identifies the route from the facility to Walgreens located at 115 West Little Creek Road as a distance of 0.55 miles with a duration time of 15 minutes when walking. The route includes a 0.3 mile walk along Granby St. Granby St. consist of 3 lanes on each side of the street.
  3. The record for resident #1 admitted to the facility’s safe secure unit on 06/19/25 contains an assessment for serious cognitive impairment that documents the resident has a serious cognitive impairment due to a diagnosis of dementia and the resident is unable to recognize danger or protect his/her own safety.
  4. The record for resident #1 contains a physical exam dated 06/15/25 that documents a diagnosis of moderate dementia w/ anxiety.
Plan of correction
Resident last seen in dining room prior to exiting community. Staff were performing 2 hour rounds at time of resident exiting. 1. All staff were in-serviced on the importance of checking all memory care doors upon arriving and d 2. Resident placed on hourly rounds for 30 days.
February 4, 2025Inspection6 violations
Inspection dates
02/04/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
22VAC40-73-610 Menu for Meals and Snacks
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 02/04/2025 at 08:27 am to 5:50 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: 67 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 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
22VAC40-73-410-A
Based on the record review the facility failed to ensure upon admission, the assisted living facility shall provide an orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of the call system.
Evidence
  1. The record for resident #1, admission date 01/18/24, did not contain documentation the facility provided an orientation to the resident and/ or their legal guardian upon admission. The orientation in the record was dated as completed on 02/04/25.
Plan of correction
What Has Been Done to Correct? Orientation was completed for the resident to correct the previous issue and ensure compliance. Memo on file with the completed orientation to state address this violation. How Will Recurrence Be Prevented? Orientations will be completed immediately upon admission and signed by residents or legal representative. Person Responsible: Executive Director Due Date: 2.11.25
22VAC40-73-680-B
Based on observation and staff interview the facility failed to ensure medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. During the medication cart observation with staff #3, the Licensing Inspector observed an unlabeled Lantus insulin pen.
Plan of correction
What Has Been Done to Correct? Each insulin pin has been put in it’s on secured holder. The holders are placed into sealable plastic bags. Copies of the label with directions, identification, etc. placed inside of sealable bag with the insulin. How Will Recurrence Be Prevented? ED, RCD, ARCD will monitor for 90 days. Weekly observation and checks to be completed. Person Responsible: Resident Care Director, Maintenance Director, Executive Director Due Date: 2.4.25
22VAC40-73-870-A
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 a tour of the facility’s outside grounds, four of the windows appeared to have a rotted windowsill.
Plan of correction
What Has Been Done to Correct? Community in the process of strategically replacing windows. Will replace windows and sills according to sections of the building. How Will Recurrence Be Prevented? Community converting from Wooden sills to concrete forms. Person Responsible: Executive Director, Maintenance Director VP of Capital Projects Due Date: 3.14.25
22VAC40-73-580-E
Based on the record review the facility failed to ensure the facility shall develop and implement a policy to monitor each resident for compliance with any needs determined by the resident’s individualized service plan or prescribed by a physician or other prescriber, nutritionist, or health care professional.
Evidence
  1. The record for resident #1 contains physician orders dated 07/18/24, and 12/03/24 that includes the following instructions: “check resident’s weight monthly and record on the fifth.” Resident’s #1 Medication Administration Records for the months of September 2024 through January 2025 did not include documentation the resident’s weight was checked monthly.
Plan of correction
What Has Been Done to Correct? Wheel chair scale has been ordered. Community will utilize this scale to ensure that non-ambulatory resident’s weights are tracked according to orders and policy. How Will Recurrence Be Prevented? RCD and ARCD will review the weights of each by the 5th of each month. Person Responsible: Resident Care Director and Assistant Resident Care Director Due Date:3.5.25
22VAC40-73-50-B
Based on the onsite record review the facility failed to obtain written acknowledgment of the receipt of the disclosure by the resident or their legal representative.
Evidence
  1. The record for resident #1, admission date 01/18/24, did not contain a written acknowledgement of the receipt of the disclosure statement by the resident or their legal representative.
Plan of correction
What Has Been Done to Correct? Resident’s file has been updated with current disclosure. A memo stating that the signed disclosure from 2.11.25 is in the file with the disclosure to address this violation. How Will Recurrence Be Prevented? Disclosures will be signed in regulation, prior to admission. Person Responsible: Executive Director Due Date: 2.11.25
22VAC40-73-870-I
Based on observation and staff interview the facility failed to ensure elevators, where used, shall be kept in good running condition and shall be inspected at least annually. Elevators shall be inspected in accordance with the Virginia Uniform Statewide Building Code (13VAC5-63). The signed and dated certificate of inspection issued by the local authority shall be
Evidence
  1. of such inspection. Evidence:
  2. The facility’s elevator inspection certificate expired 06/01/24.
Plan of correction
What Has Been Done to Correct? Inspection to correct this violation has been confirmed. February 27, 2025, Elevators will be serviced and inspected by Roanoke Valley Inspection, LLC. How Will Recurrence Be Prevented? Company has confirmed annual scheduling. Executive and Maintenance Director will ensure inspection occurs. Person Responsible: Executive Director, Maintenance Director Due Date: 2.27.25
July 2, 2024Inspection2 violations
Inspection dates
07/02/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 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
22VAC40-73-1150-A
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.
  3. 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
22VAC40-73-460-D
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
January 18, 2024Inspection1 violation
Inspection dates
01/162024, 01/18/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
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 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. A self- reported incident was received by VDSS Division of Licensing on 12/12/23 and 12/17/23 regarding allegations in the area of: Personnel 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: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation of residents, and breakfast was completed in the safe, secure environment. 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
22VAC40-73-110-1
Based on the record review and staff interview the facility failed to ensure all staff be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, informed, or disabled.
Evidence
  1. Resident’s #1 incident report dated 12/17/23 documents the following information: On the date and time of 12/10/23 @ 12:09pm, “an RMA reported resident #1 was “prevented from eating her meal, by staff #2, the resident was admonished verbally as well as poked in the shoulder by staff # 2;” “Staff #2 was suspended pending investigation and released from employment.”
  2. During an interview with staff #1, staff # 1 stated staff # 1 observed staff #2 curse at resident #1.
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 conducted abuse and neglect training with all staff. How Will Recurrence Be Prevented? Resident Care Director/designee and Executive Director/designee will review and continue with regular training and reinforce the Resident Rights. We provided Abuse and Neglect retraining to all staff. We ensure we discuss Abuse and Neglect during monthly staff meetings. Person Responsible: Executive Director
January 16, 2024Inspection7 violations
Inspection dates
01/16/2024, 01/18/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 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
22VAC40-73-970-E
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
22VAC40-90-40-C
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
22VAC40-73-870-A
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
22VAC40-73-680-D
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
22VAC40-73-290-B
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
22VAC40-73-450-C
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
22VAC40-73-350-B
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
October 3, 2023Inspection2 violations
Inspection dates
10/03/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 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
22VAC40-73-110-1
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
22VAC40-73-290-B
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
February 7, 2023Inspection8 violations
Inspection dates
02/07/2023, 02/08/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 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
22VAC40-73-260-C
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
22VAC40-73-70-A
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
22VAC40-73-350-B
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
22VAC40-73-250-D
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
  1. by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. 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.
  3. 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
22VAC40-73-430-H-1
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
  1. 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
22VAC40-73-990-C
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
22VAC40-73-970-A
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
22VAC40-73-310-D
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
February 15, 2022Inspection4 violations
Inspection dates
02/15/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 General Provisions22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 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
22VAC40-80-120-E-2
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 published by VDSS.
22VAC40-73-970-A
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.
22VAC40-73-940-A
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
  1. 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.
22VAC40-73-870-A
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.
March 16, 2021Complaint survey1 violation
Areas reviewed
22VAC40-73 BUILDING AND GROUNDS
Comments
This investigation was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint investigation was initiated on 03-16-2021 and concluded on 03-16-2021. A complaint was received by the department regarding buildings and grounds. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-870-E
Based on observation and interview, the facility failed to ensure all fixtures are kept in good repair.
Evidence
  1. Photograph reportedly taken on 01-31-2021 of room #107 was provided on 03-01-2021; revealing right side of toilet paper holder detached from wall.
  2. Conducted virtual tour of special care unit with staff #1 and staff #2, and observed right side of the toilet paper holder in room #107 detached from wall. Both staff acknowledged the detached toilet paper holder.
Plan of correction
Apartment 107 was severely damaged at discharge. At time of tour with LI, Apartment 107 was unoccupied and the door was locked because it had not had the opportunity to be made “room ready” for a new occupant. Plans for repairs had been delayed because of the community COVID status and the inability of vendors to enter the community to complete repairs. In the future the Executive Director or designee will self report any apartments damaged day discharge to LI. Apartment 107 has been repaired.
February 10, 2021Inspection4 violations
Inspection dates
Feb. 10, 2021 and Feb. 11, 2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 02-10-2021 and concluded on 02-11-2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 50. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, criminal background checks and sworn disclosures of newly hired staff, staff schedules, fire drills, fire and health inspection reports, dietary oversight, and healthcare oversight. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-450-C
Based on resident record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) included a description of identified needs.
Evidence
  1. Resident #1’s signed physician’s orders dated 01-07-2021 documented, continuous Oxygen via Nasal Cannula 2LPM; and allergies to Penicillins, Nitrofurantoin, Shellfish, and Sulfamethoxazole/Trimetheoprim.
  2. Resident #1’s current ISP dated 02-04-2021 did not document the need for continuous oxygen or the liter flow rate, nor aforementioned allergies.
  3. Resident #2’s current Uniform Assessment Instrument dated 09-14-2020 documented the need for mechanical and physical assistance with toileting and dressing; mechanical assistance with stairclimbing; and bladder incontinence weekly or more.
  4. Resident #2’s current ISP dated 09-14-2020 did not document the type of mechanical device needed for assistance with toileting, dressing, and stairclimbing; or bladder incontinence.
  5. Staff #1 and staff #2 acknowledged resident #1 and resident #2’s aforementioned needs were not identified on the ISP’s.
Plan of correction
The Resident Care Director or designee will ensure that each ISP is reviewed and updated annually or if there is a change in the resident condition to include the assessed needs as per the UAI. Resident # 1 and #2 ISP was updated to reflect assessed needs. The ISPs of other residents were reviewed to ensure compliance. Records reviewed to include identified need, oxygen orders, allergies and mechanical assistance needed. Community will continue to complete Preliminary ISP and Comprehensive ISP in conjunction with resident, family, and/or caregivers while using the History and Physical, physician orders, UAI, and other support to ensure the individualized 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 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 Preliminary ISP on the date of admission. Executive Director, Resident Care Director, and/or designee reviewed other ISPs to ensure compliance. Executive Director will complete random monthly audit of a minimum of 4 Comprehensive ISPs to ensure ongoing compliance.
22VAC40-73-480-C
Based on record review and interview, the facility failed to arrange for specialized rehabilitative services by a qualified personnel as needed by the resident, to include physical and occupational therapy services.
Evidence
  1. The “Progress Notes” [nursing notes] documented resident #2 fell on 01-09-2021.
  2. Resident #2’s signed physician’s orders dated 01-13-2021 documented, ?PT/OT [physical and occupational therapy] eval and treat- falls.?
  3. Staff #1 could not provide documentation verifying resident #2 was evaluated and treated by PT/OT as of 02-13-2021. Additionally, no documentation was provided indicating the therapists was contacted regarding the aforementioned order as of 02-13-2021.
  4. Staff #1 acknowledged the facility did not arrange for PT/OT services as ordered by the physician on 01-13-2021.
Plan of correction
Resident has been evaluated for therapy services. All physician orders for specialized rehabilitative services were reviewed. Process to refer, evaluate, and treated reviewed and re-educated with therapy partner. Resident Care Director or designee will review all physician orders daily. Resident Care Director or designee will ensure that therapeutic services, evaluation and treatment begin timely. Executive Director, Resident Care Director, or designee to complete random monthly audit of physician orders for therapy and evaluation to ensure ongoing compliance.
22VAC40-73-650-C
Based on record review and interview, the facility failed to ensure the physician's oral orders are reviewed and signed by a physician within 14 days.
Evidence
  1. Resident #1’s “Physician’s telephone/verbal order” dated 01-10-2021 documented, ?May hold Ambien until supply arrives.? The order was not reviewed and signed by a physician as of 02-11-2021.
  2. Staff #1 and staff #2 acknowledged resident #1’s verbal order was not reviewed and signed by a physician within 14 days.
Plan of correction
A signed order was obtained from the prescriber during the monitoring visit. Resident Care Director and Assistant Resident Care Director reviewed all prescriber’s oral orders to ensure that they are signed by a physician or other prescriber as required by BON and Licensing Standards. Resident Care Director, Assistant Resident Care Director, or designee will review all oral orders daily to ensure continued compliance.
22VAC40-73-680-E
Based on record review and interview, the facility failed to ensure treatments ordered by a physician or other prescriber are provided according to his instructions and documented. The documentation should be maintained in the resident's record.
Evidence
  1. Resident #1’s signed physician’s orders dated 01-07-2021 (original order dated 08-05-2020) documented, ?Oxygen- Continuous, Continuous Oxygen via Nasal Cannula 2LPM.?
  2. Continuous oxygen was not documented on resident #1’s January and February 2021 Medication Administration Record (MAR) or Treatment Administration Record (TAR). Staff #1 and staff #2 could not provide documentation verifying resident #1 received continuous oxygen daily on 01-01-2021 through 01-31-2021, and 02-01-2021 through 02-08-2021; nor could staff provide a discontinued order for the oxygen.
  3. Resident #2’s signed physician’s orders dated 01-07-2021 documented ?Vital signs- one time per day 5th at 9:30 PM. Vitals: Blood Pressure, Breathing Rate, Pulse, Temperature.?
  4. Resident #2’s February 2021 MAR documented the following vital signs: A. Blood Pressure taken on 02-01-2021 through 02-07-2021 during the 9:30 AM and 5:00 PM administration time; and on 02-08-2021 during the 5:00 PM administration time. B. Pulse taken on 02-03-2021 and 02-04-2021 during the 5:00 PM administration time. C. Breathing rate and temperature taken on 02-05-2021 during the 9:30 PM administration time.
  5. Staff #1 and staff #2 acknowledged resident #1’s oxygen was not provided in accordance with the physician’s instructions and was not documented in the resident’s record, and resident #2’s vital signs were not provided in accordance with the physician’s instructions.
Plan of correction
All oxygen orders were reviewed and revised as necessary to correlate with current physician orders. Resident Care Director to re-educate Nurse and RMAs on the 5 rights of medication administration to include re-ordering, administration, and discontinuing of medications in accordance with the physician’s order and Board of Nursing standards. Resident Care Director or designee will approve all new medication orders in the EMAR system as well as discontinuation orders. Executive Director, Resident Care Director, or designee to complete random monthly audit of physician orders to ensure ongoing compliance.