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 21, 2023 , March 24, 2023 , March 26, 2023 and April 18, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND

Comments:

Type of inspection: Complaint An unannounced complaint inspection conducted on 03/21/22 (ar 9:42 a.m./dep 5:20 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 03-9-23 regarding allegations in the areas of resident care and related services, buildings and grounds. Number of residents present at the facility at the beginning of the inspection: 85 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. On 3-24-23 Number of resident records reviewed: 5Number of staff records reviewed: 0 Number of interviews conducted with residents:4 Number of interviews conducted with staff: 7 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 #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on observation, interviews and record reviewed, the facility failed to ensure that it reported to the regional licensing office within 24 hours any major incident that has negatively affected or threatens the life, health, and safety, or welfare of any resident. Evidence: 1. On 3-21-23, when speaking with resident #3, the inspector observed a laceration to the left side of the resident?s head and bruising noted on left side of the resident?s face. Resident #3 stated falling and being sent to the emergency room for care. A check for this incident to the licensing office determined no report was received. A review of resident?s clinical notes noted incident on 2-6-23, out to emergency room (ER), cellulitis diagnosis and 1-24-23, fall out of bed, out to ER, laceration to right ear. 2. A complaint report to the office stated, resident #1 had a broken neck and had previously had a broken leg. The resident did not have a broken leg. The office did receive an incident report on the afternoon on 3-9-23 with reporting an incident for resident #1 on 3-8-23 at 08:00. This report was received after the complaint allegation received on the morning of 3-9-23. 3. The facility did not report the incident reports within the 24-hour reporting period.
Plan of Correction:	Facility shall 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. All future incidents will be reported to the licensing office as soon as possible upon notification and to not exceed 24 hours.
Standard #:	22VAC40-73-220-B
Complaint related:	No
Description:	Based on record reviewed, staff, resident and collateral interviews, the facility failed to ensure it had the required documents when a private duty personnel who are not employees of a licensed home care organization provide direct care or companion services to residents in the assisted living facility. Evidence: 1. On 3-24-23, CL-1 was providing activities of daily living to resident #2. During conversation with the resident and CL-1, it was determined that CL-1 was hired by the family to provide services to resident #2. CL-1 stated not having any credentials as direct care staff (personal aide, direct care nor nurse?s aide training). 2. On 3-24-23, staff #1 stated not having documentation of the requirements for CL-1 as a private sitter/companion caregiver for resident #1, no criminal record check, no orientation and no tuberculosis (TB) documentation.
Plan of Correction:	Care personnel hired by the family will go through community orientation, criminal background check, and TB test prior to providing care within the community. There are no other care personnel hired by the family in the community. Going forward, all third party personnel hired by family will abide by the regulations listed in state regulation 22VAC40-73-220.
Standard #:	22VAC40-73-440-H
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that an annual reassessment or reassessment due to a significant change in the resident?s condition, using the UAI, shall be utilized to determine whether a resident?s need can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: 1. On 3-24-23, resident #3?s record did not include a uniform assessment instrument (UAI). The resident?s date of admission was documented as 8-30-19.
Plan of Correction:	Records will be audited to verify residents have a UAI that complies with regulation 22VAC40-73-400. Audit to be completed by HWD and RCC with a completion date of 04/25/2023. UAI?s will be in compliance with regulation 22VAC40-73-400 by 6/1/2023. Moving forward, residents will have UAI completed prior to admission, annually and with significant change. Chart audits will be completed monthly by ED, HWD or company designee to verify ongoing compliance.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all required information for one of five residents. Evidence: 1. On 3-21-23, resident #1?s uniform assessment instrument (UAI) dated 2-3-23 documented bathing need as mechanical help/physical assistance (mh/pa); transferring need- mh; stairclimbing need- mh. The individualized service plan dated 2-6-23 did not document what mechanical help (mh) was needed. Wandering behavior documented greater than weekly and disoriented time and place spheres all the time. The ISP did not document what services to be provided. Stairclimbing documented as not performed, this assessed need not documented on the ISP. Toileting need documented mh/pa; the ISP did not document what mh and what physical assistance to be provided. The ISP did not include the identified need date and expected outcome time frame. The resident?s date of admit was noted 2-6-23.
Plan of Correction:	Records will be audited to verify residents have a UAI that is consistent with the ISP and accurately identifies the care needs of the resident and/or any assistance they need. Audit to be completed by HWD and RCC with a completion date of 04/25/2023. ISPs will be in compliance with regulation 22VAC40-73-450-C by 6/1/2023. Moving forward, residents will have preliminary ISP completed prior to admission. Comprehensive ISP to be completed within 30 days of admission, annually and with significant change. UAI to be reviewed and updated upon changes to comprehensive ISP. Chart audits will be completed monthly by ED, HWD or company designee to verify ongoing compliance.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the updated individualized service plan (ISP) included all resident?s need for three residents. Evidence: 1. On 3-21-23, resident #2?s ISP dated 11-4-22 did not include documentation of the resident?s sitter/companion/ caregiver who provides care on Monday, Tuesday, Wednesday and Thursday. The resident?s date of admit noted as 1-23-22. 2. On 3-24-23, resident #4?s ISP dated 12-15-22 did not include resident?s podiatry services, date of last service was 1-31-23. Wheeling need assessed as not performed, this need was not on the ISP. 3. On 3-24-23, resident #3?s record did not include an ISP. The resident?s date of admit was noted 8-30-19.
Plan of Correction:	Records will be audited to verify residents have a UAI that is consistent with the ISP and accurately identifies the care needs of the resident and/or any assistance they need. Audit to be completed by HWD and RCC with a completion date of 04/25/2023. ISPs will be in compliance with regulation 22VAC40-73-450-F by 6/1/2023. Moving forward, residents will have preliminary ISP completed prior to admission. Comprehensive ISP to be completed within 30 days of admission, annually and with significant change. UAI to be reviewed and updated upon changes to comprehensive ISP. Chart audits will be completed monthly by ED, HWD or company designee to verify ongoing compliance.
Standard #:	22VAC40-73-870-A
Complaint related:	No
Description:	Based on observation and staff interviewed, the facility failed to ensure that the interior of the building was maintained in good repair and kept clean and free of rubbish. Evidence: 1. On 3-24-23, the carpet in resident #5?s room was stained in various areas. According to the resident and staff #1, the stains near the window/air conditioner is water stains. There were also dark stains of various sizes near the bed and in the middle of the floor.
Plan of Correction:	Carpet has been scheduled for replacement due to overall condition. Scheduled to be replaced by 5/5/2023.