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: Aug. 15, 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 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring An on-site inspection was conducted on 8-15-24. (Ar 07:25 a.m./Dep 18:45 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 10 Observations by licensing inspector: Additional Comments/Discussion: 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 #:	22VAC40-73-50-B
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 the legal representative was retained in the resident?s record. Evidence: 1. On 8-15-24, resident #1?s record did not have written acknowledgement of receipt of the facility?s disclosure. The resident?s date of admit was noted as 8-5-24. 2. Staff #1 acknowledged the resident?s record did not have written acknowledgement of the facility?s disclosure.
Plan of Correction:	Executive Director or designee will audit 100% of residents records for acknowledgements and disclosures by September 13th and ongoing monthly to ensure completed . In compliance as of September 30th Will utilize move in checklist to ensure completion on going. Executive Director to review in QA quarterly
Standard #:	22VAC40-73-250-D
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility submitted 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. Evidence: 1. On 8-15-24, staff #9?s TB document in the record was dated 7-8-24. The staff?s date of hire was noted as 7-1-24. A discussion was conducted regarding staff?s status, was staff a transfer or a new hire. 2. Staff #1 and #2 acknowledged the staff?s TB was not within the required timeframe.
Plan of Correction:	Audit to be conducted by 9/20/2024 of all employee files for tb to be conducted prior to start date by business office manager or designee. Any employee file identified to not have TB will be reported to the Executive Director and in compliance as of September 20th. Will utilize orientation check off to audit 10% employee files monthly. Executive Director to review in QA quarterly
Standard #:	22VAC40-73-290-B
Description:	Based on observation and staff interviewed, the facility failed to ensure the posting for the name of the current on-site person in charge was current. Evidence: 1. On 8-15-24, the on-site staff person in charge posting was dated 8-13-24. 2. Staff #4 acknowledged the staff in charge posting was not current.
Plan of Correction:	Prior to leaving shift 11p-7 am shift med tech or designee will ensure staffing is posted for that day. The manager on duty will check daily. Any day not having staff posted will be reported to Executive Director and will be corrected immediately. Executive Director to review quarterly in QA to be completed by 8/30/2024
Standard #:	22VAC40-73-310-D
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the administrator provided written assurance to the resident that the facility had the appropriate license to meet the care needs of the resident at the time of admission. A signed copy by the resident or legal representative shall be kept in the resident?s record. Evidence: 1. On 8-15-24, resident #1?s record did not include a copy of the signed written assurance document. 2. Staff #1 acknowledged the resident?s record did not include a signed written assurance.
Plan of Correction:	Executive Director or designee will audit 100% of residents records for written assurance by September 20th and ongoing monthly to ensure completed . In compliance as of September 30th Will utilize move in checklist to ensure completion on going. Executive Director to review in QA quarterly
Standard #:	22VAC40-73-320-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the physical examination was within 30 days of a resident?s admission. Evidence: 1. On 8-15-24, resident #3?s physical examination date was noted as 11-23-2022. The resident?s date of admit noted as 9-28-24. 2. Staff #1 acknowledged the resident?s physical examination was not within 30 days of the date of admission.
Plan of Correction:	Audit of 100% resident records ensuring accurately dated by provider to be completed by 9/20/2024 by health and wellness director or designee. Ongoing monthly audit of minimum 10% resident records. Any identified reported to Executive Director . Identified discrepancies will be sent to the physicians by 10/5/2024 . Executive Director to review in QA quarterly.
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs. Evidence: 1. On 8-15-24, resident #3?s personal and social data noted resident?s allergy to adhesive tape. This was allergy was not documented on the resident?s ISP dated 9-15-23 and 10-15-23. 2. Resident #4?s uniformed assessment instrument dated 5-3-24 noted eating/feeding need assessed as mechanical help; this need was not on the ISP dated 5-3-24. Wheeling need assessed as mechanical help/physical assistance; the ISP noted wheeling need as mechanical help. Mobility need assessed as mechanical help/physical assistance; the ISP noted mobility need as mechanical help/ supervision. 3. Staff #1 and #2 acknowledged the residents ISPs did not include all assessed needs.
Plan of Correction:	Audit of social data sheets100 % residents to be conducted by 9/20/2024 by health and wellness director or designee. Any missing information to be reported to the Executive Director. All missing information to be corrected by 9/30/2024. The Executive Director will review at least quarterly during QA. Audit of UAI and ISP 100% residents to be conducted by 9/20/2024 by health and wellness director or designee for inaccuracies. Any discrepancy identified will be reported to the Executive Director. Inaccuracy will be corrected and new ISP/UIA will be printed placed in chart by 9/30/204. HWD will review at least 20% of residents UAI/ISPs during weekly CCR meeting. All changes in conditions to be made by health and wellness director or designee ongoing for accuracy. Executive Director to review in QA quarterly
Standard #:	22VAC40-73-870-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the interior and exterior of the building was maintained in good repair and kept clean and free of rubbish. Evidence: 1. On 8-15-24 during a tour, the roof on the rear of the building, the back dock, kitchen area entrance from rear is missing a portion of the fascia. The fascia on the front porch covering area is in need of repair. 2. The carpet in resident?s room #136 is in need of cleaning. The ceiling tile above the table near the juice bar in the dining area in the safe, secure unit contains a large brown circular spot. 3. Staff #1 and #7 acknowledged the interior and exterior areas of the facility is in need of repair.
Plan of Correction:	Weekly audit of building and grounds by Director of Maintenance or Designee utilizing tels. Will notify Executive Director of any items needed to schedule repairs. Audit completion as of 9/20/2024 To be completed with repairs as of 9/30/2024. Director of Maintenance or designee will conduct weekly reviews of TELs and complete tasks required. The Executive Director will review at least quarterly during QA.
Standard #:	22VAC40-80-120-E-2
Description:	Based on observation and staff interviewed, the facility failed to ensure the findings of the most recent inspection of the facility was posted. Evidence: 1. On 8-15-24, the most recent inspection for the facility was not posted. Staff #4 and the inspector search the front area for the document but was not successful in locating the facility last inspection. 2. Staff #1 and #4 acknowledged the most recent inspection for the facility was not posted.
Plan of Correction:	Executive Director or designee to ensure most up to date inspection posted. Completed as of 8/27/24. Manager on Duty or designee will audit daily as part of the daily checklist to ensure compliant. Executive Director will review monthly.
Standard #:	22VAC40-90-40-B
Description:	Based on record reviewed 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 8-15-24, staff #9?s criminal background check document in the record was dated 1-20-23. The sworn disclosure was dated 7-8-24. The staff?s date of hire noted as 7-1-24, during a discussion with staff #2, it was determined the staff was a new hire and not a transfer staff. 2. Staff acknowledged; the staff did not have a criminal background check within the required time requirement.
Plan of Correction:	Audit to be completed as of all employee files to ensure background and sworn statements are in files by 9/20/2024 by Business Office Manager or designee. The Business office Manager will conduct an ongoing audit of minimum 10% staff files every month to ensure background and sworn statements completed prior to 30th day of employment.. Any identified missing report to Executive Director. Executive Director to review at least quarterly in QA.