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: June 30, 2023

Complaint Related: No

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 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal An on-site Renewal Inspection conducted on 6-5-23 (Ar 08:30/dep 5:10), 6-7-23 (08:54/ dep 5:15) and 6-9-23 (09:53/ dep 1:25). The census on 6-5-23 was 81. A medication pass observation was conducted, activity on the safe, secure unit- observed. Staff and resident interviews conducted. An exit meeting was conducted all three days with the administrator and staff. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-B
Description:	Based on record reviewed and staff interviewed, the facility failed to all direct care staff attend at least 18 hours of training annually. Evidence: On 6-9-23, staff #7?s training record documented 16.25 hours of annual training.
Plan of Correction:	Staff records to be reviewed weekly for compliance with annual training. Review of all current records for compliance will be conducted. Completion date to be 08/04/2023
Standard #:	22VAC40-73-210-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure at least two of the required hours of training shall focus on infection control and prevention. When adults with mental impairments reside in the facility, at least four of the required hours shall focus on topics related to the resident?s mental impairment. Evidence: 1. On 6-9-23, staff #3?s training document noted .75 hours of infection control and prevention training. Staff #7?s document noted .50 hours of infection control and prevention training.
Plan of Correction:	Infection control hours for all staff has been increased to state minimum of 2 hours per employee. Completion date to be 08/04/2023
Standard #:	22VAC40-73-260-C
Description:	Based on observation and staff interviewed, the facility failed to ensure a listing of all staff who have current first aid or CPR was posted in the facility so that the information is readily available to all staff at all times. The posting should also be kept up to date. Evidence: 1. On 6-7-23 following a check of the first aid kit, staff #10, the staff listed as the person in charge, was asked where the facility?s listing of staff with first aid and CPR was posted. The listing was not posted and not current. Staff #10?s name was not on the list that was provided later during the day.
Plan of Correction:	All first aide kits will be audited monthly by Nursing team to ensure all required product is available in the kit. System in place and started as of 07/01/2023.
Standard #:	22VAC40-73-310-D
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure prior to admission that it provided written assurance to the resident that the facility has the appropriate license to meet the care needs at the time of admission. A signed copy of the document shall be kept in the resident?s record. Evidence: 1. On 6-5-23, resident #1?s record did not include signed documentation of written assurance information provided to the resident and or legal representative prior to the admission date 9-27-22.
Plan of Correction:	Written assurance will be reviewed during move in process of all residents. Residents entering the facility will have one to coincide with their UAI. System in place as of 07/01/2023
Standard #:	22VAC40-73-310-H
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 for five of ten records reviewed. Evidence: 1. On 6-5-23, resident #1?s record included a physician?s order dated 4-11-23 for Celexa. The record did not include a treatment plan for this prescribed psychotropic medication. 2. Resident #6 record included a physician?s order dated 3-13-23 for Buspar. The record did not include a treatment plan for this prescribed psychotropic medication. 3. Resident #7?s record included a physician?s order dated 5-11-23 for Ativan and Haloperidol. The record did not include a treatment plan for these prescribed psychotropic medications. 4. On 6-7-23, resident #8?s record included documentation of Buspar. The record did not include a treatment plan for this prescribed psychotropic medication. 5. Resident #9?s record included documentation of Zyprexa. The record did not include a treatment plan for this prescribed psychotropic medication.
Plan of Correction:	HWD and RCC to conduct review of residents on psychotropic medications. Team will coordinate with doctor for treatment plan for residents on psychotropic medications. Completion date to be 08/04/2023.
Standard #:	22VAC40-73-320-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the results of a risk assessment documenting the absence of tuberculosis (TB) 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 was conducted for one of ten resident records reviewed. Evidence: 1. On 6-5-23, resident #1?s record did not include documentation of an initial TB results prior to the documented 9-27-22 admission date.
Plan of Correction:	As part of the admission process, initial TB will be verified prior to resident move in. System in place and started as of 07/01/2023.
Standard #:	22VAC40-73-350-B
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 ten records. Evidence: 1. On 6-5-23, resident #4?s record did not include documentation of a sex offender report. The resident?s date of admission was documented as 3-28-23.
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. System in place as of 07/01/2023. Completion of audit to be completed by 08/04/2023.
Standard #:	22VAC40-73-380-B
Description:	Based on record reviewed and staff interviewed, the facility failed to the resident?s personal and social information document was kept current. Evidence: 1. On 6-5-23, resident #3?s admitting physical examination dated 3-27-23 documented resident?s allergy to Brimonidine and lactose intolerant. The allergy section of the personal and social data form is blank. The admit date section is also blank. 2. Resident #4?s admit date, vocation and organ donation section of the personal and social data form are blank. 3. Resident #5?s mental health and substance abuse information on the personal and social data form are blank.
Plan of Correction:	Upon move in, resident Social Data sheet will be updated digitally and printed out from electronic record. System in place as of 07/01/2023. Existing resident social data sheets will be updated, printed and updated in physical chart with a completion date of 08/04/2023. This sheet will be used as the new Social Data Sheet moving forward.
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed the comprehensive individualized service plan (ISP) included all assessed needs. Evidence: 1. On 6-5-23, resident #1?s admitting physical examination document dated 9-22-22 noted physical therapy, occupational therapy and skilled home health nurse. The resident?s ISP dated 9-22-22 and 4-19-23 did not documented services. Resident?s date of admit noted as 9-27-22. 2. Resident #3?s record noted resident receiving podiatry services, document dated 4-28-23. The ISP dated 5-13-23 did not include this service. Resident?s date of admit noted as 4-27-23.
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 08/04/2023. ISPs will be in compliance with regulation 22VAC40-73-450-C by 8/4/2023. 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
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. On 6-5-23, resident #2?s ISP dated 5-21-23 did not include documentation of resident?s physical therapy services. The record included a signed order dated 5-1-23 to continue home health services. Interview with resident on 6-5-23, resident stated receiving physical therapy services to help gain strength to walk. Resident?s date of admit noted as 7-28-21. 2. Resident #5?s record noted resident receiving podiatry services, documents in record dated 2-5-23 and 5-15-23. The ISP dated 5-13-23 did not include this service. Resident?s date of admit noted as 12-22-16. 3. Resident #7?s record noted resident receiving wound care services for foot ulcer not on ISP dated 11-4-22. Resident?s date of admit noted as 1-23-22.
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 08/04/2023. ISPs will be in compliance with regulation 22VAC40-73-450-F by 8/4/2023. 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 #:	22VAC40-73-580-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a written agreement to the effect of the resident having meals routinely consumed in resident?s room was signed and dated by both the resident and the license or administrator and filed in the resident?s record. Evidence: 1. 0n 6-5-23 during interview with resident #2, the resident stated consuming all meals in room. Resident #2?s individualized service plan (ISP) dated 5-21-23 did not document resident?s eating all meals in the resident?s room. 2. A copy of the written agreement to consume all meals in room was not in effect, signed and dated by both the resident and the licensee or administrator and filed in the resident #2?s record. 3. Resident?s record noted an order for Ensure or Boost for protein intake and has a diagnosis of dementia.
Plan of Correction:	Written agreement will be made with any residents routinely consuming meals in their room. This will also be noted on resident?s care plan and ISP. Completion date to be 08/04/2023
Standard #:	22VAC40-73-680-I
Description:	Based on observation and staff interviewed, the facility failed to ensure that the facility?s medication administration record (MAR) included all information. Evidence: 1. On 6-5-23, during the medication pass observation with staff #7, resident #1?s June 2023 MAR did not include diagnosis for Memantine and Liquifilm Tears. 2. Staff #7 acknowledged the aforementioned medications on the June 2023?s MAR for resident #1 did not have a diagnosis.
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. HWD and RCC will supervise all training for staff. Training to be completed by 08/04/2023.
Standard #:	22VAC40-73-980-C
Description:	Based on observation and staff interviewed, the facility failed to ensure the first aid kits were checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. Evidence: 1. On 6-7-23 during a check of the facility?s first aid kits with staff #6, #10 and #11, the first aid kits were missing the following items: (a) adhesive tape (Flourish); (b) assorted band aids (Hall 1 nurse?s station); (c) blanket (Flourish); (d) assorted roller gauze (Vehicle); (e) plastic bags (Flourish); (f) scissors (Hall 1); (g) flashlight (Vehicle) extra batteries (Hall 1); (h) thermometer (Hall 1 and Vehicle) and (i) Tweezers (Vehicle).
Plan of Correction:	All first aide kits will be audited monthly by Nursing team to ensure all required product is available in the kit. Team will also ensure all product in the kit is not expired. System in place and started as of 07/01/2023.
Standard #:	22VAC40-90-40-B
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. Evidence: 1. On 6-7-23, the review of the new hires list highlighted fifty-nine staff members. Nine of the currently employed staff?s CRC document noted ?being processed? from 10-17-22 to 5-31-23. Sixteen employees did not have CRCs from 11-2-22 to 5-31-23.
Plan of Correction:	BOM to conduct review of all team members? state background checks to ensure that the final copy received from the state is in their chart and not stored digitally. All records will be maintained physically instead of digitally moving forward. Completion date to be 08/04/2023