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Public Google reviewers rate Commonwealth Senior Living at the Ballentine highly. Reviewers highlight: compassionate and attentive nursing staff, clean and beautifully renovated building. Reviewer identity is not verified, and online reviews may not capture everything. Schedule a visit to assess the fit directly.
Families considering The Ballentine can expect a highly praised, clean, and renovated facility with a staff frequently described as compassionate, professional, and welcoming. While most reviews highlight exceptional care and a warm community atmosphere, one recent reviewer noted concerns regarding declining food quality and staff turnover following a change in ownership.
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Key Review Excerpts
“The Ballentine is my new home. It is WONDERFUL. Ms.Pat has been so very helpful and kind to me since I got here 4/5/25. She and her staff have been supportive, on point, encouraging, helpful and educating me about my Issues. Clean building, making improvements, Med Techs are fantastic 🤩. Plenty to do.”
“The quality of the food and the care by the staff have both decreased, while the price has increased. Some of my favorite staff members havve left, & I'm afraid that's because of the change in ownership.”
“Where to start? The Ballentine is the Taj Mahal of Norfolk. What a great facility. Clean, quiet but more importantly the staff. What a wonderful, friendly group of people.”
Source: VA State Licensing Agency
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
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.
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.
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.
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.
Based on the record review and staff interview the facility failed to ensure the comprehensive individualized service plan ( ISP
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
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
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
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. 5. The record for resident #1 contains a physical exam dated 06/15/25 that documents a diagnosis of moderate dementia w/ anxiety.
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 ? 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.
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
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.
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.
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.
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.
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.
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 of such inspection. Evidence: 1. The facility?s elevator inspection certificate expired 06/01/24.
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
Based on the record review and staff interview the facility failed to ensure doors that lead to unprotected areas shall be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates. Residents who reside in safe, secure environments may be prohibited from exiting the facility or the special care unit if applicable building and fire codes are met. Evidence: 1. Resident?s #1 incident reports for ?resident elopement? dated 6/07/24 and 6/14/24 documents the following: ?sweet memories (facility?s safe secure unit) courtyard gate left unlocked by community?s landscaping company;? ?resident breached the secured gate;? ?resident found walking on the sidewalk by the community.? 2. The record for resident #1 contains a progress note dated 6/07/24 that documents the following: ?lawn care workers left the back gate open and resident walked out of the gate and walked across the street.? 3.During an interview with staff #1, staff #1 reported that resident #1 left the safe secure unit?s courtyard through an unlocked gate located outside. Staff #1 reported the courtyard gate was left unlocked by the community?s landscaping company. 4. During observation with staff #2, the secured gate located outside of the safe secure unit?s courtyard was observed to lead to a sidewalk area that is not protected or secured by the facility. Staff #2 confirmed the secured gate observed was the gate left unlocked and the gate resident #1 exited during the elopement incident on 06/07/24.
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
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
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.
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
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.
Based on the record review the facility failed to ensure the comprehensive individualized service plan ( ISP
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.
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.?
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).
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
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.
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