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: May 6, 2024 and May 7, 2024

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 22VAC40-80 THE LICENSING PROCESS

Comments:

Type of inspection: Renewal An unannounced on-site renewal inspection was conducted on 5-6-24 (Ar 07:36 a.m./dep 17:46 p.m.) Day 1. The facility census was 81. Day 2 (Ar 08:13/dep 4:50 p.m.). 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. 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-E
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that staff had training relevant to the population in care. Evidence: 1. On 5-7-24, staff #6 and #7?s training record did not have documentation of oxygen training. The facility currently has a resident who is prescribed oxygen via nasal cannula continuously. 2. Staff #2 acknowledged the staff?s record did not have documentation of oxygen training
Plan of Correction:	Audit of staff files will be conducted by 5/31/2024 by business office manager or designee Any staff identified without trainings requires will be reported to Executive Director Any additional 3rd party entities (ie oxygen, catheter) will have training for direct care staff within 30 days of the resident start of care. Completion date 6/10/2024. Health and wellness director or designee will monitor quarterly
Standard #:	22VAC40-73-250-D
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that the health information required by these standards was maintained at the facility and included in the staff record for each staff person. Evidence: 1. On 5-7-24, staff #1?s record did not have documentation of the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form. Staff?s date of hire was noted as 4-16-24. 2. Staff #6?s record did not have documentation of a current TB assessment. Staff?s date of hire noted as 6-25-07. 3. Staff #1, #2 and #3 acknowledged the staff?s record did not have documentation of a current TB assessment.
Plan of Correction:	Business Office Manager or Designee will audit all staff files ensure prior to start date tb completed and ensure annually completed. Date to be completed 6/10/2024. Upon new hire business office manager or designee to ensure that tb completed and monthly audits to be conducted by business office manager or designee. Executive director to review monthly
Standard #:	22VAC40-73-260-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that staff maintained current certification in adult first aid. Evidence: 1. On 5-7-24, staff #7?s First aid and CPR certification was expired as of 3-14-24. Staff?s date of hire noted as 2-21-24. 2. Staff #2 and #3 acknowledged the staff?s first aid certification was not current.
Plan of Correction:	All staff files to be audited for first aid/cpr 5/31/2024 completion and expiration by 5/31/2024. Audit to be completed by health care director or designee. Any staff files identified without first aide/cpr will be reported to Executive D. First aide/CPR classes for all staff to be completed by 6/30/2024 and certificates to be held in binder in HWD office and will be reviewed monthly. Executive Director will review at least quarterly during QA
Standard #:	22VAC40-73-260-C
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure that the listing of all staff who have current certification in first aid or CPR was kept updated. Evidence: 1. On 5-7-24, the first aid/CPR posting for the facility did not include all nursing department staff who are first aid or CPR certified. 2. Staff #2 acknowledged the first aid/CPR posting did not include all required staff and not updated.
Plan of Correction:	All CPR certified staff will be audited by health and wellness director or designee and be posted by 5/31/2024 and reviewed monthly by HWD and RCC. Executive Director will review during QA at least quarterly
Standard #:	22VAC40-73-290-A
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure the written work schedule include the names and job classification of all staff working. Evidence: 1. On 5-6-24, the concierge/activity schedule did not include the staff?s full name nor job classification. 2. The housekeeping/maintenance schedule provided did not include the staff's full name and job classification. 3. Staff #1, #2 and #4 acknowledged the staff schedules provided did not include all required information.
Plan of Correction:	Audit to be conducted by 5/31/2024 by business office manager or designee to ensure that a schedule for each dept with first and last name will also include the job classification for each associate. Date to be corrected 6/10/2024 and monitor ongoing monthly by executive director or designee.
Standard #:	22VAC40-73-310-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a documented interview between the administrator or a designee responsible for admission and retention decisions, the individual, and the legal representative, if any. Evidence: 1. On 5-6-24, resident #3?s record did not have documentation of an interview between the administrator and or facility designee. 2. Staff #2 and #3 acknowledged the resident?s record did not have a documented interview.
Plan of Correction:	All UAI?s will be documented as interview with administrator prior to admission to facility. All resident charts will be audited by 5/31/2024 by Health and wellness director , resident care coordinator or designee . Date of completed 6/10/2024
Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that it did not admit or retain individual with any prohibited conditions or care needs without supporting documentation. Evidence: 1. On 5-6-24, resident #9?s May 2024 medication administration record (MAR) noted resident is prescribed Sertraline. The physician?s order dated 4-26-24 noted the Sertraline. The record did not include a treatment plan for this prescribed psychotropic medication. 2. Resident #13?s May 2024 MAR noted resident is prescribed Trazadone. The physician?s order dated 3-22-24 noted the Trazadone. The record did not include a treatment plan for this prescribed psychotropic medication. 3. Staff #2 and #3 acknowledged, the residents? record did not have a treatment plan for these psychotropic medications prior to the inspection on 5-6-24.
Plan of Correction:	Audit will be conducted by Health and Wellness Director or designee of all residents charts to ensure psychotropic medication treatment plan is UTD by 5/31. Any resident identified needing will be reported to Executive Director . Health and Wellness Director or designee will faxed to Doctor for signature by 06/10/2024. A psychotropic binder will be held in Health and wellness director office and will be reviewed monthly. Reviewed during CCR monthly. Executive Director will review quarterly during QA
Standard #:	22VAC40-73-380-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident personal and social information was kept updated. Evidence: 1. On 5-7-24, resident #4?s personal and social information document, the admission date and advance directive information section were blank. 2. Staff #2 and #3 acknowledged, the aforementioned resident?s social data was not updated.
Plan of Correction:	Audit will be conducted by Health and wellness director or designee to ensure social data sheet are completed by 5/31/2024. Any resident Identified will be reported to Executive Director. Health and Wellness Director or designee will report to family and have filled out completely. Upon admission, social data sheet will be reviewed by Health and Wellness Director, Resident Care Coordinator, and Executive Director to ensure all information is complete as part of the move in process. Date of compliance 6/10/2024 and ongoing . Executive Director will review at least quarterly during QA
Standard #:	22VAC40-73-410-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that upon admission, the assisted living facility shall provide an orientation for new and their legal representative. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgement shall be signed and dated, and such documentation shall be kept in the resident?s record. Evidence: 1. On 5-7-24, the orientation document in resident #6?s record was not signed and dated by the resident, who is assigned to the safe, secure unit neither the legal representative. The resident?s date of admit noted as 12-20-23. 2. Staff #2 acknowledged the orientation document was not signed and dated by the resident neither the resident?s legal representative.
Plan of Correction:	Audit of all resident files by 5/31/2024 by health and wellness director or designee . Health and Wellness Director or Executive Director will upon move-in the move-in orientation sheet will be signed by resident/POA. Date of compliance will be 6/10/2024
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s individualized service plan (ISP) included all assessed needs. Evidence: 1. On 5-7-24, resident #4?s record noted resident as a fall risk. The facility?s fall risk evaluation document noted a score of 14 (moderate risk) on 7-30-23. The facility?s fall risk evaluation noted a score of 16 (moderate risk) on 3-9-24. This assessment was not documented on the resident?s ISP dated 7-12-23. 2. Staff #3 acknowledged the resident?s ISP did not include the fall risk assessment.
Plan of Correction:	All fall risk will be audited and reviewed by 5/31/2024 by health and wellness director or designee to ensure correct calculation. All fall risk greater than 12 will be correct risk is on ISP. Health and wellness director or designee will provide All LPNs will fall risk eval completion training by_6/10/2024 .Fall risk will be reviewed by Health and Wellness Director and Resident Care Coordinator after each fall. Executive Director will review quarterly during QA
Standard #:	22VAC40-73-450-E
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee, the person who developed the plan and by the resident or the legal representative. These requirements also apply to reviews and updates of the plan. Evidence: 1. On 5-7-24, resident #6?s record noted resident had a change in condition. The physician completed an assessment for safe secure unit on 3-12-24. The facility and family documented condition change for placement in the safe secure unit on 3-14-24. 2. The resident?s ISP was last signed and dated 1-13-24.
Plan of Correction:	Any changes in resident condition will be Reviewed during CCR meeting and noted on UAI/ISP and family will be contacted to document changes by Health and Wellness Director and Resident Care Coordinator date of compliance 6/10/24 and ongoing. Will be reviewed during CCR and Executive Director will review quarterly
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that the reviewed and updated individualized service plan (ISP) included all needs. Evidence: 1. On 5-6-24, resident #2?s ISP dated 5-3-24 did not include the name of the coordinated dialysis facility where resident receive services, when or frequency of attendance and what to do when resident refuses attendance. 2. Staff #2 and #3 acknowledged the resident?s ISP did not include all information for dialysis services.
Plan of Correction:	Health and Wellness Director or designee will audit Any resident receiving dialysis services charts. Any missing documentation will be reported to Executive Director and Health and wellness director or designee will include all information needed and plan for refusals will be documented date of compliance 6/10/2024 All charts will be audited by Health and Wellness Director or designee to identify orientation forms missing. Any Orientation form missing will be reported to Executive Director and Health and Wellness Director or designee will have signed and dated by resident or legal representative health and wellness director or designee will monitor ongoing. Executive director will review audits quarterly during QA
Standard #:	22VAC40-73-580-A
Description:	Based on document reviewed and staff interviews, the facility failed to ensure that when any portion of the assisted living facility is subject to inspection by the Department of Health, the facility shall be in compliance with those regulations, as evidenced by a subsequent annual inspection from Virginia Department of Health. The report shall be retained at the facility for a period of at least two years. Evidence: 1. On 5-6-24, the health inspection provided was dated 3-17-23. The facility did not have documentation of contact with the health inspector prior to the health inspection expiring nor after the expiration. 2. Staff #1 acknowledged; the health inspection had expired. There was no written documentation of contact with the Health Department to obtain an inspection prior to its expiration date.
Plan of Correction:	All staff files will be audited by 6/05/2024 to ensure license Up to date by business office manager or designee Any staff identified with expired license will be reported to Executive Director . Business office manager or designee will monitor licensure expiration date and prior to the expiration date begin contacting the licensee official to ensure documentation of contact prior to expiration made. At least 10% of the staff files will be audited monthly by business office manager or designee Any missing items will be reported to ED. Completed 6/10/2024 and ongoing monthly review. Executive Director will review at least quarterly during QA
Standard #:	22VAC40-73-640-D
Description:	Based on observations and staff interviews, the facility failed to ensure that it readily accessible at least one pharmacy reference book, drug guide, or medication handbook for nurses that is no more than two years old as reference materials for staff who administer medication. Evidence: 1. On 5-6-24, staff #7 was asked where the facility?s drug book was kept. The book was located on the nurse?s station. The drug reference book was for year 2019. 2. On 5-7-24, staff #11 was asked where the facility?s drug book was kept. Staff obtain a book dated year 2019 from top of the medication cart. 3. Staff #7 and #11 acknowledged the drug reference book 2019 was more than two years old.
Plan of Correction:	All Carts will be audited for drug book by Health and Wellness Director or Designee by 5/21/24. An up-to-date drug book will be placed on med cart and will be audited yearly for expiration. Any drug book older than 2 years will be removed and discarded. . Completed by 5/31/2024
Standard #:	22VAC40-73-660-A-7
Description:	Based on observations and staff interviewed, the facility failed to ensure medical supply and equipment was appropriately labeled. Evidence: 1. On 5-6-24, the glucometer for resident #14, was not labeled. Staff #6 acknowledged the glucometer was not labeled. 2. On 5-7-24, the glucometer for resident #4 was not labeled. Staff #11 acknowledged the glucometer was not labeled.
Plan of Correction:	A med cart audit will be conducted by Health and Wellness Director or Designee to ensure all glucometers are labeled properly. Any glucometers not labeled properly will be reported to Health and Wellness Director and Executive Director . All glucometers will be labeled with resident?s name upon admission. Cart audits will be conducted weekly by 5/31/2024 to ensure labeling of glucometers. Audits will be Reviewed weekly and as needed by HWD and Resident Care Coordinator and completed by 5/31/2024. Executive Director will review audits quarterly
Standard #:	22VAC40-73-680-I
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the facility? medication administration record (MAR) included all required information. Evidence: 1. On 5-6-24, during the medication observation pass with staff #7, resident # 11?s May 2024 MAR did not have a diagnosis, condition, or specific indications for the medication, Gemtesa being administered. 2. Resident #13? s May 2024 MAR did not have diagnosis or condition for medications, Norvasc, Aspirin, Chlorthalidone, Trazadone, and Spironolactone. 3. Staff #7 acknowledged the medications did not have a diagnosis on the May 2024 MAR on 5-6-24.
Plan of Correction:	An audit will be conducted of all residents MARs to ensure all medications have diagnosis by 5/31/2024 by health and wellness director or designee . Any medications identified without dx will be reported to ED and physician to get dx if needed. All MARs will be reviewed for diagnosis monthly during cart audits by 5/31/2024 Reviewed and completed by 6/10/2024. Executive Director will review quarterly during QA
Standard #:	22VAC40-73-680-M
Description:	Based on observation and staff interview the facility failed to ensure that medications ordered for PRN administration was available, properly labeled for the specific resident and properly stored at the facility. Evidence: 1. On 5-6-24, during the medication pass with staff # 6, resident #9?s May 2024 medication administration record (MAR) noted resident was prescribed Bisacodyl suppositories. Staff searched for the items but could not locate the resident?s PRN. 2. During the medication pass with staff #7, resident #12?s May 2024 MAR noted resident was prescribed Ibuprofen 800 mg and Refresh Tears 0.5%. These items were not available in the facility on 5-6-24. 3. Staff #7 acknowledged the resident?s PRN medication noted were not available.
Plan of Correction:	Cart audits will be conducted by 5/31/2024 for all med carts weekly to ensure all meds are on the cart by health and wellness director . Any medication found needed for cart will be reported to Health and Wellness Director and Executive Director to ensure med is ordered. Health and Wellness Director will review audits weekly. Executive Director will review at least quarterly. Completed by 6/10/2024
Standard #:	22VAC40-73-870-A
Description:	Based on observation and staff interviewed, the facility failed to ensure that the interior of all buildings shall be maintained in good condition. Evidence: 1. On 5-7-24, the ceiling in the dining area near the window in the safe, secure room was observed to have a large brownish colored circle on the tile. The ceiling in the common area in the safe, secure unit was observed to have large and small areas of a brownish colored circles on the ceiling tiles. Staff #8 stated that the circles are from water leakage, but the source is unknown. 2. Staff #8 acknowledged that there were brownish colored circle areas on the ceiling tiles in areas of the safe, secure unit.
Plan of Correction:	Environmental Service Director or Designee will ensure that the interior shall be maintained in good condition .Audit will be completed by 5/31/2024 Environmental service director , designee or executive director. To continue audit monthly by environmental service director or designee. Any issue present to be reported to the Executive Director for any repairs necessary or designee. Date to be corrected 6/10/2024
Standard #:	22VAC40-73-950-E
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure that all staff, residents, and volunteers review the facility?s emergency preparedness plan initially and semi-annually. The review shall be documented by signing and dating. Evidence: 1. On 5-6-24, the emergency preparedness plan for the facility is not being reviewed and signed and dated by all staff on all shifts. 2. Staff #2 and #4 acknowledged the facility?s emergency plan is not being reviewed with all staff on all shifts.
Plan of Correction:	Audit to be completed regarding training by business office manager or designee by 5/31/2024 Environmental Service Director or designee will ensure that emergency preparedness is reviewed, signed and dated by all staff on all shifts semiannually. Corrected date 6/10/2024 and ongoing
Standard #:	22VAC40-73-960-B
Description:	Based on observation and staff interviewed, the facility failed to ensure that the fire and emergency evacuation drawing posted in the facility included all required information. Evidence: 1. On 5-6-24, during a tour with staff #4, the fire and evacuation drawing observed on the first floor did not include the assembly areas, telephones and/or area of refuge. The postings on the second floor also did not include this information. 2. Staff #4 acknowledged the fire and emergency evacuation posting did not include all required information.
Plan of Correction:	Fire and evacuation drawing audit by Environmental service director or designee and corrected to include all information per regulation by 5/31/2024. Date of corrected 6/10/2024 by Environmental Service Director or designee . Executive director will review at least quarterly during qa
Standard #:	22VAC40-73-960-C
Description:	Based on observation and staff interviewed, the facility failed to ensure the emergency numbers are posted. Evidence: 1. On 5-7-24, the inspector inquired of staff #7 where the emergency numbers and/or Poison Control Center number was located. Staff search for the number at the first-floor nurses? station near the resident?s record room; but could not find the Poison Control Center telephone number. 2. Staff on the second-floor nurses? station- was asked where the emergency telephone numbers, poison control number was located. Staff #13 searched for the numbers but were not able to locate the emergency and Poison Control Center number. 3. Staff # 2 and #3 acknowledged the emergency numbers, Poison Control Center number is not available near the telephones in the facility.
Plan of Correction:	Health and Wellness Director or designee will ensure that emergency numbers are posted. Audit of all nursing stations conducted by 5/31 by health and wellness director or designee. Date to be corrected 6/10/2024. Executive director to review at qa
Standard #:	22VAC40-73-990-C
Description:	Based on documented provided and staff information, the facility failed to ensure that at least every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies in the facility are practiced. This information shall be maintained for at least two years. Evidence: 1. On 5-6-24, the review of the facility?s resident emergency/emergency preparedness plan was conducted. All staff in the facility is not documented as participating in the required review and/or practice for resident emergency. 2. Staff #2 and #4 acknowledged the resident emergency review and practice exercise was not completed and /reviewed by all staff in the facility.
Plan of Correction:	Business office manager or designee to audit all staff files by 5/31/2024. Environmental Service Director or designee will ensure that all staff on each shift shall participate in an exercise in which the procedures for resident emergencies in the facility are practiced at least every 6 months. Completed date of 6/10/24 and ongoing
Standard #:	22VAC40-90-40-B
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure that no employee shall be permitted to work in a position that involved direct contact with residents until a background check has been completed, unless the person works under the direct supervision of another employee for whom a background check has been completed in accordance with the requirements of the background check regulation (22VAC40-90) Evidence: 1. On 5-6-24, staff #10 provided the inspector with the sworn disclosure and background check documentation and list of all new staff since the last inspection. 2. Staff #10 (CRC- 22)?s record did not have a background check; staff?s date of hire noted as 11-0-23. 3. Staff #CRC-14, record did not have documentation of a background check; staff?s date of hire noted as 9-6-23. 4. Staff #1 and #10 acknowledged the staff record did not have documentation of a background check document.
Plan of Correction:	An audit will be conducted by Business Office Manager by 5/31/2021 ongoing prior to start of employment the background check completed and filed Date to be corrected 6/10/24 and monitor monthly . Report any missing to executive director .