Inspection Reports for Commonwealth Senior Living at the Ballentine
7211 Granby Street, VA, 23505
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
7.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
19% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
71 residents
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Monitoring
Census: 71
Deficiencies: 2
Jul 9, 2025
Visit Reason
An unannounced monitoring inspection was conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in the areas of Resident Care and Related Services and the Safe Secure Environment.
Findings
The investigation supported the self-report of non-compliance with standards related to the facility's failure to secure doors leading to unprotected areas and inadequate supervision of residents, resulting in an elopement incident involving a resident with serious cognitive impairment.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure doors leading to unprotected areas were monitored or secured with appropriate devices, allowing a resident to exit the safe secure unit unsupervised. |
| Facility failed to provide adequate supervision of resident schedules, care, and activities, including prevention of falls and wandering, resulting in a resident elopement. |
Report Facts
Number of residents present: 71
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
Distance from facility to location of resident elopement: 0.55
Duration of walk from facility to Walgreens: 15
Plan of correction duration: 30
Inspection Report
Renewal
Census: 67
Deficiencies: 6
Feb 4, 2025
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with applicable standards and regulations for licensing renewal.
Findings
The inspection identified multiple violations including failure to obtain written acknowledgment of disclosure receipt, incomplete resident orientation upon admission, lack of monitoring resident weight as ordered, improper medication labeling, maintenance issues with building windows, and expired elevator inspection certificate.
Deficiencies (6)
| Description |
|---|
| Failed to obtain written acknowledgment of the receipt of the disclosure by the resident or their legal representative. |
| Failed to provide orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of the call system upon admission. |
| Failed to develop and implement a policy to monitor resident compliance with individualized service plans or physician orders, specifically monthly weight checks. |
| Medications did not remain in pharmacy issued container with prescription label attached until administered; observed unlabeled insulin pen. |
| Facility failed to maintain interior and exterior of buildings in good repair and free of rubbish; rotted windowsills observed. |
| Elevator inspection certificate expired and was not current as required by state code. |
Report Facts
Residents present: 67
Resident records reviewed: 6
Staff records reviewed: 3
Resident interviews: 3
Staff interviews: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Conducted the inspection and is contact for questions |
| Executive Director | Named as person responsible for multiple violations and plans of correction | |
| Resident Care Director | Named as person responsible for monitoring resident weights and medication labeling corrections | |
| Assistant Resident Care Director | Named as person responsible for monitoring resident weights and medication labeling corrections | |
| Maintenance Director | Named as person responsible for medication labeling and building maintenance corrections | |
| VP of Capital Projects | Named as person responsible for building maintenance corrections |
Inspection Report
Monitoring
Census: 66
Deficiencies: 2
Jul 2, 2024
Visit Reason
An unannounced monitoring inspection was conducted following a self-reported incident received on 2024-06-07 regarding allegations in the areas of Resident Care and Related Services and the Safe Secure Environment.
Findings
The investigation supported the self-report of non-compliance with standards related to unsecured doors leading to unprotected areas and inadequate supervision of residents, resulting in resident elopement incidents. Violations were issued and plans of correction were proposed to prevent recurrence.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure doors leading to unprotected areas were monitored or secured through devices conforming to applicable building and fire codes, resulting in resident elopement through an unlocked courtyard gate. |
| Facility failed to provide adequate supervision of resident schedules, care, and activities, including prevention of falls and wandering, contributing to resident elopement. |
Report Facts
Residents present: 66
Resident records reviewed: 1
Staff records reviewed: 0
Interviews with residents: 0
Interviews with staff: 1
Resident elopement duration: 30
Inspection Report
Monitoring
Census: 62
Deficiencies: 1
Jan 16, 2024
Visit Reason
An unannounced monitoring inspection was conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of personnel.
Findings
The investigation supported the self-report of non-compliance with standards related to staff conduct, resulting in violations issued. Staff training on abuse and neglect was conducted and employment separation occurred for the involved staff member.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure all staff be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, informed, or disabled. |
Report Facts
Number of residents present: 62
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with staff: 1
Inspection Report
Renewal
Census: 62
Deficiencies: 7
Jan 16, 2024
Visit Reason
An unannounced renewal inspection was conducted on January 16 and January 18, 2024, to assess compliance with applicable standards and regulations for Commonwealth Senior Living at the Ballentine.
Findings
The inspection identified multiple violations including failure to properly post the current on-site person in charge, incomplete sex offender screening prior to admission, incomplete individualized service plans, medication administration errors, maintenance issues such as water in the basement, incomplete fire and emergency drill documentation, and employment of a staff member with barrier crimes in their criminal history.
Deficiencies (7)
| Description |
|---|
| Failed to develop and implement a procedure for posting the name of the current on-site person in charge. |
| Failed to ascertain and document sex offender status prior to admission for a resident with anticipated stay over three days. |
| Failed to ensure individualized service plan (ISP) was completed within 30 days after admission and included identified dietary needs. |
| Failed to ensure medications were administered in accordance with physician's instructions, specifically Atenolol given despite contraindications. |
| Failed to maintain interior and exterior of buildings in good repair and free of rubbish; water observed in basement. |
| Failed to ensure fire and emergency evacuation drill records included required details such as notification method, participants, conditions, time, weather, and problems. |
| Failed to ensure persons required to obtain a criminal history report were ineligible for employment if report contained barrier crimes; staff with two convictions employed. |
Report Facts
Residents present: 62
Resident records reviewed: 8
Staff records reviewed: 4
Resident interviews conducted: 3
Staff interviews conducted: 4
Dates Atenolol administered against physician order: 7
Fire and emergency evacuation drills missing documentation: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the renewal inspection |
| Business Office Manager | Responsible for ensuring current listings of on-site person in charge, sex offender registry checks, and employee record reviews | |
| Resident Care Director | Responsible for ensuring individualized service plans and medication administration compliance | |
| Maintenance Director | Responsible for building maintenance and fire drill documentation | |
| Executive Director | Responsible for reviewing employee records and individualized service plans |
Inspection Report
Monitoring
Census: 64
Deficiencies: 2
Oct 3, 2023
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with applicable standards and laws, following a self-report received regarding personnel allegations.
Findings
The inspection found non-compliance with standards related to staff conduct and posting of the on-site person in charge. Violations included failure to ensure staff respect residents' rights and failure to post the current on-site person in charge.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure all staff are considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirmed, or disabled. |
| Facility failed to develop and implement a procedure for posting the name of the current on-site person in charge. |
Report Facts
Number of residents present: 64
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the inspection |
| Executive Director | Person responsible for corrective action related to staff conduct violation | |
| Business Office Manager | Person responsible for corrective action related to posting on-site person in charge |
Inspection Report
Monitoring
Census: 57
Deficiencies: 8
Feb 7, 2023
Visit Reason
An unannounced monitoring inspection was conducted on February 7 and 8, 2023, to assess compliance with applicable standards and regulations at Commonwealth Senior Living at the Ballentine.
Findings
The inspection found multiple violations including failure to report major incidents within 24 hours, incomplete annual TB risk assessments for staff, lack of posted certification listings for staff, missing written assurance documentation for resident admission, failure to ascertain sex offender status prior to admission, incomplete discharge documentation, and inadequate fire and emergency drill documentation and participation.
Deficiencies (8)
| Description |
|---|
| Failed to report to the regional licensing office within 24 hours any major incident affecting residents. |
| Failed to ensure annual TB risk assessments were completed for staff. |
| Failed to post a listing of staff with current certification in first aid or CPR. |
| Failed to provide written assurance to resident that the facility has appropriate license at admission. |
| Failed to ascertain and document sex offender status prior to admission. |
| Failed to provide a dated statement at discharge documenting actions taken to assist resident in discharge and relocation. |
| Failed to ensure fire and emergency drills were conducted on each shift quarterly as required. |
| Failed to ensure staff participated in emergency procedure exercises at least every six months with proper documentation. |
Report Facts
Number of residents present: 57
Number of resident records reviewed: 8
Number of staff records reviewed: 6
Number of resident interviews: 3
Number of staff interviews: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Conducted the inspection |
| Staff #7 | Acknowledged failure to submit incident report for hospital admissions | |
| Staff #3 | Had missing annual TB risk assessment documentation | |
| Staff #4 | Had missing annual TB risk assessment documentation | |
| Staff #2 | Acknowledged lack of fire and emergency drill documentation and missing certification listing | |
| Executive Director | Person responsible for corrective actions and compliance | |
| Business Office Manager | Responsible for tracking TB assessments and certification listings | |
| Maintenance Director | Responsible for fire and emergency drill documentation and training |
Inspection Report
Renewal
Census: 50
Deficiencies: 4
Feb 15, 2022
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with licensing requirements and facility standards.
Findings
The inspection identified multiple deficiencies including failure to maintain the building in good repair, lack of an annual fire inspection report, incomplete fire drill documentation, and failure to post the most recent inspection findings.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure the interior of the building was maintained in good repair and kept clean and free of rubbish, including missing smoke detector, burnt out light bulb, broken dresser, and gaps in service doors. |
| Facility failed to obtain at least an annual fire inspection report by the appropriate fire official; last fire inspection dated March 17, 2020. |
| Facility failed to ensure fire drills were conducted on each shift for each quarter; missing documentation for 7am-3pm shift during third quarter. |
| Facility failed to post the findings of the most recent inspection report; last posted inspection dated 2/19/2020 while last inspection was on March 16, 2021. |
Report Facts
Residents in care: 50
Inspection duration: 6.5
Inspection duration: 2.67
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 16, 2021
Visit Reason
A complaint investigation was initiated due to a complaint received by the department regarding buildings and grounds at the facility.
Findings
The investigation found that the facility failed to ensure all fixtures were kept in good repair, specifically a detached toilet paper holder in room #107. The apartment was unoccupied and repairs were delayed due to COVID-19 related vendor access issues, but the apartment has since been repaired.
Complaint Details
Complaint related: Yes. The evidence supported the allegations of non-compliance with standards or law regarding building and grounds maintenance.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure all fixtures are kept in good repair; right side of toilet paper holder in room #107 detached from wall. |
Inspection Report
Renewal
Census: 50
Deficiencies: 4
Feb 10, 2021
Visit Reason
A renewal inspection was initiated on February 10, 2021 and concluded on February 11, 2021. The inspection was conducted remotely due to a state of emergency health pandemic declared by the Governor of Virginia.
Findings
The inspection identified multiple violations including failure to ensure Individualized Service Plans (ISP) included descriptions of identified needs, failure to arrange for specialized rehabilitative services as ordered, failure to ensure physician's oral orders were reviewed and signed within 14 days, and failure to provide treatments ordered by a physician according to instructions and documentation requirements.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure the Individualized Service Plan (ISP) included a description of identified needs. |
| Facility failed to arrange for specialized rehabilitative services by qualified personnel as needed, including physical and occupational therapy services. |
| Facility failed to ensure the physician's oral orders were reviewed and signed by a physician within 14 days. |
| Facility failed to ensure treatments ordered by a physician or other prescriber were provided according to instructions and documented in the resident's record. |
Report Facts
Resident census: 50
Resident records reviewed: 3
Staff records reviewed: 3
Physician order date: Jan 7, 2021
Physician order date: Jan 13, 2021
Physician verbal order date: Jan 10, 2021
Medication Administration Record (MAR) dates: Jan 1, 2021
Medication Administration Record (MAR) dates: Feb 8, 2021
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