VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Charter Senior Living of Newport News
655 Denbigh Boulevard
Newport news, VA 23608
(757) 890-0905

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: March 29, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

A Representative with the Division of Licensing conducted an unannounced, mandated renewal inspection on 03/29/2022 and concluded on 03/29/2022. At the point of entrance the facility Administrator was available and on-site. The Licensing Inspector reviewed 4 staff records and 7 resident records, toured the facility physical plant and reviewed additional facility documentation for compliance. Please contact the facility Licensing Inspector Kimberly Rodriguez, at 757-586-4004 or by email at kimberly.rodriguez@dss.virginia.gov for additional questions or concerns.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on staff record review the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents shall submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: On 03/29/2022 while reviewing staff record #2 with a date of hire of 3-14-2022 record did not contain a risk assessment nor did the facility provide any additional documentation.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-325-B
Description:	Based on resident record review the facility failed to ensure the fall risk rating shall be reviewed and updated annually. Evidence: While reviewing resident record #3 on 03/29/2022, the residents last fall risk assessment was completed on 09-14-2019.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review the facility failed to ensure all residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110, at least annually. Evidence: While reviewing resident record #5, on 03/29/2022 the Licensing inspector observed the last uniform assessment in the resident record was dated 12/20/2019. The facility did not provide additional documentation.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	The facility failed to ensure the comprehensive individualized service plan shall be completed within 30 days after admission. Evidence: On 03/29/2022 while reviewing resident record #4, resident #4's record contained an individualized service plan dated 05/25/2021 and read at the top, " Initial ISP". Resident #4's record did not contain a comprehensive service plan nor did the facility provide additional documentation.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to ensure Individualized service plans shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. The review and update shall be performed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons. Evidence: While reviewing resident record #1 on 03/29/2022, the Licensing Inspector observed that resident #1's Individualized service plan expired on 3/10/2021.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-550-G
Description:	Based on staff record review the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each staff person. Evidence of this review shall be the resident's, his legal representative's or responsible individual's, or staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's or staff person's record. Evidence: While reviewing staff record #3 on 03/29/2022, staff record #3 hired on 02/10/2020 did not contain a review of resident rights, nor did the facility provide any additional documentation.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-940-A
Description:	Based on facility record review the facility failed to ensure an assisted living facility shall comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Reports of the inspections shall be retained at the facility for at least two years. Evidence: While meeting with the facility Administrator on 03/29/2021, the Administrator was not able to provide the facility fire inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.