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: Dec. 15, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES

Comments:

Type of inspection: Complaint An unannounced complaint inspection conducted on 10-14-22 (ar 10:50 a.m./dep 3:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 9-13-22 regarding allegations in the areas of resident care and related services, buildings and grounds, staffing and food/nutrition. Number of residents present at the facility at the beginning of the inspection: 82 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. On 10-14-22 Number of resident records reviewed: 4 Number of staff records reviewed: 5 Number of interviews conducted with residents:0 Number of interviews conducted with staff: Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations area(s) of non-compliance with standard(s) or law were valid. A violation notice was issued; any violation(s) not related to the complaint 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1140-A
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee shall determine whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident?s file. Evidence: 1. On 10-18-22, resident #4?s record did not include documentation of the licensee, administrator, designee?s justification for placement on the safe, secure unit. The record also did not include documentation of the resident?s six-month assessment for continued placement in the safe, secure unit. The resident?s date of admission was documented as 4-6-22 2. Staff acknowledged the resident?s assessment documents for placement on the safe, secure unit by the licensee, administrator or designee was not in the resident?s record.
Plan of Correction:	Residents residing in the secured unit will be evaluated prior to admission, 6 months within their first year and yearly per state regulations. HWD and RCC to complete audit of existing residents by 01/15/2023.
Standard #:	22VAC40-73-1140-B
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure within four months of the starting date of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairment. Evidence: 1.On 10-14-22 during a complaint inspection regarding staff training, staff #4?s record did not have documentation of the required 10 hours of cognitive training within 4 months of employment. Staff?s record documented 6 hours of cognitive training (the document did not have a date). The staff?s date of employment was dated as 3-31-21. 2. The staff acknowledged the staff?s record did not have documentation of the required hours of cognitive training.
Plan of Correction:	BOM to monitor staff training of team members in the community and ensure that the team member is provided training in compliance with state regulations. Team members training will be audited for compliance by BOM by 01/31/2023.
Standard #:	22VAC40-73-50-B
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure written acknowledgement of the receipt of the disclosure by the resident or legal representative was retained in the record of one of four records reviewed. Evidence: 1. On 10-18-22 resident #2?s record did not include a disclosure nor written receipt of the disclosure. The resident?s date of admission documented as 5-30-22. 2. Staff #1 acknowledged the resident?s record did not include written receipt of the disclosure nor a copy of the disclosure.
Plan of Correction:	A full audit of resident files will be conducted to ensure resident?s files contain a signed acknowledgement of receipt. Any resident missing the disclosure in the audit will be presented to the resident or POA for review and signature. BOM to audit files of residents by 12/31/2022 and obtain signatures of missing resident?s disclosures by 01/31/2023
Standard #:	22VAC40-73-120-A
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a staff?s record included documentation of orientation and training required within the first seven working days of employment. Evidence: 1. On 10-14-22 staff #9?s record did not include documentation of orientation and training. Staff?s date of hire documented as 9-6-22. 2. Staff #1 acknowledged the staff?s record did not include documentation of required orientation and training.
Plan of Correction:	Team members will obtain orientation and training required prior to their 7th day of employment. BOM to monitor all new hires first month of employment to ensure team members are obtaining the training required by ALF regulations. Audit of existing team members will be conducted by 01/31/2023
Standard #:	22VAC40-73-300-B
Complaint related:	Yes
Description:	Based on document reviewed, record reviewed and staff interviewed, the facility failed to ensure documentation of significant happenings or problems experienced by residents, including complaints or incidents or injuries related to physical or mental conditions were documented in the facility?s communication book. Evidence: 1. On 10-18-22, during a complaint inspection regarding a physical injury, the facility?s communication book did not include documentation of resident #4?s 911 transport to a local hospital. The resident?s record documented on 7-16-22, resident sent out for left shoulder pain. The record did not document the resident?s return or result of the emergency room visit. 2. Resident #1?s record documented resident sent out to the emergency room following 911 call on 8-26-22 and returned on 8-31. The communication book did not document this incident. 3. On 10-18-22 staff #2 acknowledged the resident?s record did not include follow-up documentation of the ER visit. The facility?s communication book also did not include documentation of this incident.
Plan of Correction:	Facility communication book to be reviewed by HWD and RCC frequently and ensure proper documentation is in both the chart and the communication book. Management will retrain staff on proper documentation and where to put information. Training to be completed by 01/15/2023
Standard #:	22VAC40-73-310-H
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any of the prohibitive conditions or care needs without supporting documentation. Evidence: 1. On 10-18-22 resident #3?s record documented resident prescribed Lexapro and Seroquel psychotropic medications. The record did not include a treatment plan for these psychotropic medications. 2. Staff #1 acknowledged the resident?s record did not include a treatment plan for prescribed psychotropic medications.
Plan of Correction:	HWD and RCC to conduct full audit of residents on psychotropic medications. Team will ensure treatment plan is in place for residents with those medications. Audit to be completed by 01/15/2023.
Standard #:	22VAC40-73-325-B
Complaint related:	Yes
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a fall risk rating was completed after a fall for resident. Evidence: 1. On 10-28-22, resident #1, record documented falls on the following dates with no fall risk rating: 2-20-22, 4-14-22, 4-16-22, 5-27-22 and 7-29-22. The fall risk ratings in the record were dated 2-4-20 and 5-22-20. 2. Staff #1 acknowledged the resident?s record did not include a fall risk rating following each fall as required.
Plan of Correction:	HWD and RCC will review all falls during morning meeting. Falls will be followed up by HWD and RCC in morning meeting with management team. Fall risk rating will be updated after each reported fall by RCC and HWD. Audit of current resident charts will be conducted for compliance by 01/15/2023.
Standard #:	22VAC40-73-350-B
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it ascertained, 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 for one of four records. Evidence: 1. On 10-18-22, resident #2?s record did not include documentation of a sex offender report. The resident?s date of admission was documented as 5-30-22. 2. Staff acknowledged the resident?s record did not include documentation of a sex offender report.
Plan of Correction:	Potential residents touring the community will be checked for sex offender. Sales Director or designee will perform sex offender checks prior to admission into the community. All residents charts will be audited for compliance with sex offender checks. Audit to be completed by 12/31/2022.
Standard #:	22VAC40-73-410-A
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure upon admission, orientation for a new resident and their legal representative was provided and documentation of such was kept in the record of one of four records reviewed. Evidence: 1. On 10-18-22, resident #2?s record did not include documentation of orientation to the facility upon admission or following admission. The resident?s date of admission was documented as 5-30-22. 2. Staff acknowledged the resident?s record did not include documentation of orientation to the facility.
Plan of Correction:	New residents admitted to the community will be given a proper orientation to the community. ED or designee will ensure orientation is completed on day of admission. Current residents charts will be audited for compliance by 01/31/2023.
Standard #:	22VAC40-73-440-H
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure an annual reassessment and reassessment due to a significant change in the resident?s condition, using the uniform assessment instrument (UAI) was utilized to determine whether a resident?s need can continue to be met by the facility and whether continued placement in the facility was in the best interest of the resident for two of four resident?s record. Evidence: 1. On 10-18-22, resident #1?s record did not include an updated/reassessed annual UAI. The UAI in the record was dated 1-24-20 and 3-4-20. The resident?s record documented resident received hospice services; (hospice recertification documentation dated 2-7-22 and a discharge documentation dated August 2022). The resident?s date of admit to the facility was documented 2-4-20. 2. Resident #?s UAI in the record was dated 5-24-29 and 5-29-20. The resident?s dates of admit to the facility were documented 2-11-21 (2-26-18). 3. Staff acknowledged the residents? record did not include an update/annual reassessment using the UAI document to determine condition change and continued placement.
Plan of Correction:	RCC and HWD will conduct full audit of residents at the community for updated UAI. Audit to be completed and UAIs will be current by 1/15/2023
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the comprehensive individualized service plan (ISP) was completed within 30 days after admission and included all required assessed needs for four of four records. Evidence: 1. On 10-18-22, resident #2?s record did not include a preliminary service plan and a 30-day comprehensive plan was not in the record. The resident?s UAI was dated 5-13-22 and the date of admission was documented as 5-30-22. 2. Resident #3?s ISP was dated 2-29-20 with a review end date of Feb 2021. The resident?s date of admission was documented as 2-11-21 (2-26-18). 3. Resident #4?s ISP dated 5-4-22 and provided by staff #11 did not include the need date and expected outcome time frame. 4. Resident #1?s ISP dated 7-15-22 did not include the need date and expected outcome time frame. 5. Staff acknowledged the residents? record did not include an ISP, updated ISP and required ISP information.
Plan of Correction:	Residents? preliminary ISP will be completed with admission to community. Resident will be observed for 30 days after admission and an ISP will be developed based on the resident?s first 30 days at the community. ISP will be presented to the resident and/or family for review and signature. ISP to be updated on change of condition and/or annual review. Attempts to obtain signatures will be noted if parties are unavailable timely. Audit to be completed by 01/31/2023
Standard #:	22VAC40-73-450-D
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP). Evidence: 1. On 10-18-22, resident #1?s record included documentation on 2-7-22 from a licensed hospice organization recertification for services. The record also documented hospice services discontinued August 2022. The ISP dated 7-15-22 did not include hospice services. 2. Staff acknowledged the resident?s ISP did not document hospice services.
Plan of Correction:	Hospice service provided to residents at community will be noted in care plan. Team will establish frequent meetings with hospice providers providing care to our residents. HWD and RCC to coordinate with hospice. Audit of existing care plans with hospice involvement will be audited and corrected by 01/31/2023.
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee (the person who had developed the plan), and the resident or his legal representative. These requirements shall also apply to reviews and updates of the plan. Evidence: 1. On 10-18-22, resident #1?s ISP dated 7-15-22 was not signed by the resident and/or legal representative. 2. Resident #4?s ISP not signed and dated by the developer and not signed by the resident/le al representative. 3. Staff acknowledged the residents? ISPs were not signed and dated.
Plan of Correction:	HWD and RCC will conduct audit of residents at the community. ISPs will be current and up to date. Required signatures or attempt to obtain signatures due to scheduling conflicts will be noted. HWD and RCC to complete by 01/15/2023.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition for two of four records reviewed. Evidence: 1. On 10-18-22, resident #1?s ISP was not updated to include the resident?s change in condition, resident admission/discharge from hospice services. 2. Resident #3, ISP in record was last dated 2-29-20. 3. Staff acknowledged the residents? ISPs were not updated at least once every 12 months or when there was a significant change in the resident?s condition.
Plan of Correction:	HWD and RCC will conduct audit of residents at the community. ISPs will be current and up to date. Required signatures or attempt to obtain signatures due to scheduling conflicts will be noted. HWD and RCC to complete by 01/15/2023,
Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to follow its medication management plan to ensure resident?s prescription medications and any over-the-counter drugs and supplements ordered are filled and refilled in a timely manner to avoid missed dosages for one of four resident?s record reviewed. Evidence: 1. On 10-18-22, during a complaint inspection regarding medications, resident #3?s July 2022 medication administration record (MAR) documented resident?s medication was not available to administer: Seroquel not available 7-6-22 thru 7-10-22 and Macrobid not available 7-1 thru 7-10-22. The resident?s nursing notes did not document medication not being available. 2. Staff acknowledged the resident?s record noted resident?s medication not available to administer.
Plan of Correction:	Team members with the credentials to pass medication will be trained on reordering low medication and inform HWD and RCC of any medication that is not present at the community. Team member will document appropriately when medication is unavailable. HWD and RCC to perform training to team members with the credentials to pass medication. Training for team to be completed by 01/31/2023.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the medication administration record (MAR) for three of four records reviewed included all requirements. Evidence: 1. On 10-18-22 during a complaint inspection regarding medications, resident #?1?s September 2022 MAR did not include the initials of direct care staff administering the medications on 9-3-22 (Seroquel). August 2022 MAR did not include initials on 8-29-22 and 8-30-22 (Seroquel); 8-30-22 and 8-31-22 (Clonidine) and 8-29-22, 8-30-22 and 8-31-22 (Senokot). 2. Resident #3?s September 2022 MAR did not include initials on 9-8-22 (Seroquel and Nitrofuran) and 9-25-22 and 9-29-22 (Vitamin D3). August 2022 MAR did not include initials for Oscal, Nitrofuran, Seroquel and Levothyroxine. July 2022 MAR did not include initials for Aspirin, Synthroid, Seroquel and Macrobid. 3. Resident #4?s September 2022 MAR did not include initials for Aricept, Namenda, Mefformin, Soft Gel-Omega 3, Seroquel, Zocor, Lisinopril and Glipizide. 4. On 10-18-22 staff #2 acknowledged the residents? MARs did not include the initials of the direct care staff administering the medications.
Plan of Correction:	Team members who administer medication will receive training on passing their medications and what to do in the event of a hole in the MAR. Charter has also upgraded their MARs to EMAR which will be completely up and running by 01/01/2023. HWD and RCC will supervise all training for staff.
Standard #:	22VAC40-73-870-A
Complaint related:	Yes
Description:	Based on observation and staff interviewed, the facility failed to ensure the interior of the interior of the building was maintained in good repair and kept clean and free of rubbish. Evidence: 1. On 10-14-22 during a tour of the facility for a compliant inspection of the building having a hole in the ceiling and water leaks, repair of the ceiling on the second floor was observed being completed. Staff #1 staff the ceiling was being repaired due to water damage. 2. Staff acknowledged the ceiling in the building needed repair and was being fixed.
Plan of Correction:	Charter leadership has hired a vender to diagnose the roof of the building. Maintenance team has been replacing stained ceiling tiles where patch work had been done on the roof and the leak is no longer present. Vender recommends routine maintenance at this time and patching of any areas of the roof that have damage. Roof in good condition according to vender. Patches will be patched as problems arise. Diagnosis of roof was completed on 12/15/2022. Maintenance to clear off any remaining debris and perform routine maintenance on existing roof per recommendations of vender?s report. Ceiling tiles to be replaced by 01/15/2023.
Standard #:	22VAC40-73-870-D
Complaint related:	No
Description:	Based on documents and staff interviewed, the facility failed to ensure the building was kept free of infestations of insects and vermin. Evidence: 1. On 10-14-22 during a complaint inspection regarding bedbugs in the facility, staff #1 acknowledged the facility did have an issue with bedbugs. 2. On 10-18-22, pest control invoices provided documented treatment for bedbugs were completed on 9-8-22 and 5-27-22. 3. Staff acknowledged the facility was being treated for bed bugs.
Plan of Correction:	Maintenance team to monitor complaints of bugs in the community and address all concerns promptly. Team members will be training on how to properly put in work orders and report pest issues promptly to the maintenance team. Training to be completed by 01/31/2023.
Standard #:	22VAC40-90-40-B
Complaint related:	No
Description:	Based on the employee record review and staff interviewed, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee. 1. On 10-14-22, staff #7?s record did not have documentation of a criminal background record check (CRC). The staff?s date of hire was documented as 11-29-21. 2. Staff acknowledged the aforementioned staff?s record did not have documentation of a criminal background record check.
Plan of Correction:	BOM to monitor staff training of team members in the community and ensure that the team member is provided training in compliance with state regulations. Team members training will be audited for compliance by BOM by 01/31/2023.