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. 23, 2024 and Dec. 26, 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: Renewal An unannounced mandated renewal inspection conducted on 12-23-24 with two inspectors from the PLO (Ar 10:32 a.m./Dep 17:50 p.m.). Day 2- one inspector, Ar 09:15/ Dep 15:25 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: 76 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: 2 Number of interviews conducted with staff: 9 Observations by licensing inspector: breakfast/lunch meal, medication pass 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 #:	22VAC40-73-1080-A
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure prior to being admitted or retained in a safe, secure environment, a resident must have a cognitive impairment due to a primary psychiatric diagnosis of dementia and be unable to recognize danger or protect his own safely and welfare. Evidence: 1. On 12-26-24, resident #6?s assessment of serious cognitive impairment dated 9-20-24 did not indicate that the resident has a serious cognitive impairment. Resident was place in safe, secure unit upon admission on 9-26-24. 2. Staff #3 acknowledged the aforementioned resident, prior to placement on the secure unit, did not have a diagnosis of serious cognitive impairment by an independent clinical psychologist or physician licensed to practice in the Commonwealth.
Plan of Correction:	The Health and Wellness Director and or designee will have audited 100% of residents records by 1/21/2025 for cognitive impairment due to primary psychiatric diagnosis of dementia and be unable to recognize danger or protect his own safety and welfare for all residents admitted into the safe and secure environment. The Executive Director will review in the Quality Assurance Meeting Quarterly. In compliance by February 4th 2025
Standard #:	22VAC40-73-120-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure staff orientation included the facility?s organizational structure. Evidence: 1. On 12-26-24, staff #9?s record did not have documentation of receiving the facility?s organizational structure. 2. Staff #4 acknowledged the staff?s record did not include documentation acknowledging receipt of the facility?s organization structure.
Plan of Correction:	The Business Office Manager or designee will audit 100% of staff records for signed copies of the Organizational Chart structure by January 24, 2025. The Business Office Manager or designee will audit new staff records monthly. The Executive Director will review in Quarterly Assurance Meeting Quarterly. In compliance as of January 31, 2025.
Standard #:	22VAC40-73-320-A
Description:	Based on record and staff interviewed, the facility failed to ensure the physical examination form included all required information. Evidence: 1. On 12-26-24, resident #6?s physical examination statement documented the resident was considered ambulatory. The resident was admitted to the facility?s safe, secure unit which is non-ambulatory. 2. Staff #3 acknowledged the aforementioned resident?s physical examination form did not include the correct classification.
Plan of Correction:	The Health and Wellness Director or designee will audit all Resident Physical Examination records by January 14, 2025. Upon admission, the Health and Wellness Director will review the Resident?s Physical Examination record for correct classification of Ambulatory or Non-Ambulatory. The Executive Director will review in Quality Assurance Meeting Quarterly. In compliance as of February 4, 2025.
Standard #:	22VAC40-73-380-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s personal and social information was kept current. Evidence: 1. On 12-23-24, resident #1?s DSS social data and mental health determination form noted the resident?s date of admit was 3-26-23. The facility?s face sheet noted resident?s physical move in date as 3-28-23. Staff #4 stated the resident?s physical move in date was 3-28-23. 2. Resident #3?s DSS social data noted resident?s physical admission date was 10-10-23. The facility?s face sheet and DSS mental health form noted physical move in date as 10-6-23. Staff #4 stated the resident?s physical move-in date was 10-6-23. 3. Staff #4 acknowledged the aforementioned residents? social data was not kept current.
Plan of Correction:	The Health and Wellness Director or designee will audit all Resident Social Information Data Sheets to ensure current information documented by January 24, 2025. The Health and Wellness Director will ensure corrections are made when changes occur to keep current. The Executive Director will review in Quality Assurance Meeting Quarterly. In compliance by January 31, 2025
Standard #:	22VAC40-73-450-F
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 12-23-24, resident #3?s uniformed assessment instrument (UAI) dated 4-10-24 noted resident disoriented sometime to time and place spheres. This need was not documented on the ISP dated 4-10-24.
Plan of Correction:	The Health and Wellness Director or designee will Audit 100 % of Resident Individualized Service Plans and correct inaccurate information by January 21, 2025. The Health and Wellness Director or designee will conduct weekly audits ongoing. The Executive Director will review in Quality Assurance Meeting Quarterly. In compliance by January 31, 2025
Standard #:	22VAC40-73-550-G
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s rights and responsibilities was reviewed annual. Evidence: 1. On 12-26-24, staff #9?s record did not have documentation of annual acknowledgement of resident?s rights and responsibilities. Staff?s date of hire noted as 5-17-23. 2. Staff #3 and #4 acknowledged the aforementioned staff?s record did not have documentation of annual rights review.
Plan of Correction:	The Business Office Manager or designee will audit 100% of staff records for signed copies of the Resident?s Rights, and any missing copies to be obtained by January 24, 2025. The Business Office Manager or designee will audit new staff records monthly. The Executive Director will review in Quality Assurance Meeting Quarterly. In compliance by January 31, 2025
Standard #:	22VAC40-73-610-B
Description:	Based on observation and staff interviewed, the facility failed to ensure the menus for meals and snacks for the current week was dated and posted in an area conspicuous to residents. Evidence: 1. On 12-23-24, the menu and snacks for the current week was not posted in the facility. 2. Staff #5 acknowledged the current menu and snacks was not posted.
Plan of Correction:	The Memory Care Director or designee will ensure menus are posted in conspicuous area for residents daily. The Executive Director or Manager on Duty will check menu posting daily. In compliance as of January 21, 2025
Standard #:	22VAC40-73-660-A
Description:	Based on observation, resident and staff interviewed, the facility failed to ensure medications was stored in a manner consistent with current standards of practice. Evidence: 1. On 12-26-24, resident #1?s individualized service plan (ISP) noted the resident?s medications were self-administered. A check of the storage of resident?s medication observed the medications were not stored in a locked container/area. The resident medications included control medication (Xanax/Alprazolam) which was not in a locked area/container. Resident #1 stated, the medication has always been in that particular drawer, resident pointed to the drawer where the medications were located. The facility?s medication policy (Policy No: MED-001) noted on page 2, Medication Storage, medications ?must be stored per regulatory standards?. 2. Staff #3 acknowledged the aforementioned resident?s medication was not stored according to current standards of practice.
Plan of Correction:	The Health and Wellness Director or designee will audit all storage areas of residents allowed to Self-Administer medications. All medications will have proper locked storage for medications. The Registered Medication Aide or Licensed Practical Nurse will verify daily these storage areas are locked during the 7-3 shift and 3-11 shift. The Executive Director will review in the Quality Assurance Meeting Quarterly. In compliance by January 31, 2025
Standard #:	22VAC40-73-680-C
Description:	Based on document reviewed, staff interviewed and observation, the facility failed to ensure a resident?s medication was administered not earlier than one hour before and not later than one hour after the facility?s standard dosing schedule. Evidence: 1. On 12-26-24, during the medication pass observation with staff #8, the following 08:00 a.m. medications for resident #7 were administered at 09:37 a.m.: Biotin, Donepezil, Memantine, Omeprazole, Oyster shell calcium plus D, and Vitamin B-12. 2. Staff #3 stated the facility had extended dosing hours. 3. Review of the facility?s medication policy submitted during the initial application did not document extended dosing hours. 4. Staff #1 acknowledged the aforementioned resident?s medication was not administered within the dosing schedule time.
Plan of Correction:	The Health and Wellness Director or designee will in-service staff on medication administration and the one hour before or after dosing schedule by January 24, 2025. A daily audit of medication administration times will be conducted by the Health and Wellness Director or designee. Daily discrepancies will be reported to the Executive Director. The Executive Director will review in the Quality Assurance Meeting Quarterly. In compliance as of January 31, 2025
Standard #:	22VAC40-73-700-2
Description:	Based on record reviewed, staff interviewed and observation, the facility failed to ensure it posted the ?No Smoking-Oxygen in Use? sign in a room where oxygen was in use. Evidence: 1. On 12-26-24, resident #5?s record noted resident is prescribed oxygen at bedtime. The room did not have a ?No Smoking-Oxygen in Use? sign posted. 2. Staff #2 and #3 acknowledged the aforementioned resident?s room did not have the required ?No Smoking-Oxygen in Use? sign where oxygen is in use.
Plan of Correction:	The Health and Wellness Director or designee will audit 100% of resident?s using oxygen to ensure ?No Smoking Oxygen In Use Signs? are clearly posted on the resident?s door by January 14, 2025. The Registered Medication Aid will alert the Health and Wellness Director or designee if any resident using oxygen does not have a posted sign on the resident?s door. The Executive Director will review in the Quality Assurance Meeting Quarterly. In compliance by January 14, 2025.
Standard #:	22VAC40-73-860-I
Description:	Based on staff interviewed and observation, the facility failed to ensure hazardous materials are in a locked area and not accessible to other residents. Evidence: 1. On 12-26-24, unsupervised work area with sanding saw, putty knife, an approximately 2 feet of a 2X4 piece of lumber and debris was observed first floor hallway near the bistro and receptionist area. 2. Staff #4 located the worker responsible for the unsupervised worked area.
Plan of Correction:	The Environmental Service Director or designee will educate vendors on site to ensure they are aware of the population and all Hazardous materials should be in a locked area when not attended to prevent accessibility by the residents. The Environmental Service Director will monitor each vendor on site in the community. The Executive Director will review in Quality Assurance Meeting Quarterly. In compliance by January 31,2025
Standard #:	22VAC40-73-870-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the interior of the building was maintained in good repair. Evidence: 1. On 12-23-24, during a tour of the facility with staff #2, room #108?s wall was observed to have dark scuffed marks and paint tearing along the entrance walls and closet door to the room. 2. Staff #2 acknowledged the room?s wall was in need of repair.
Plan of Correction:	The Environmental Service Director or designee will weekly audit the building and grounds to ensure the interior of building and grounds are in good repair. Any unacceptable areas will be reported immediately to Executive Director, and corrected. The Executive Director will review in Quality Assurance Meeting Quarterly. In compliance by February 14, 2025
Standard #:	22VAC40-73-890-C
Description:	Based on staff interviewed and observation, the facility failed to ensure glare was kept to a minimum in rooms used by residents. When necessary to reduce glare, coverings shall be used for windows and lights. Evidence: 1. On 12-23-24, the overhead light on the first floor near the nurse station, hall 1 and the overhead light near the bistro was observed not having coverings. 2. Staff #2 acknowledged the overhead lights were not covered to reduce glare.
Plan of Correction:	The Environmental Service Director or designee will weekly audit lights and coverings to ensure glare is at a minimum . The Environmental Service Director or designee will utilize the Tels system to manage tasks. Any identified areas will be reported immediately to the Executive Director, and corrected. The Executive Director will review in Quality Assurance Meeting Quarterly. In compliance by January 24, 2025
Standard #:	22VAC40-73-970-A
Description:	Based on staff interviewed and documents reviewed, the facility failed to ensure fire and emergency evacuation drills frequency and participation was in accordance with the current edition of the Virginia Statewide Fire Prevention Code. The drills for each shift in a quarter shall not be conducted in the same month. Evidence: 1. On 12-26-24, fire drills date was noted as 12-4-24 (9a-4p); 12-6-24 (15:00); 12-12-24 (630a -245p/ 330p); 10-31-24 (16:00- 16:15); 9-27-24 (11:45-12:00 p); 8-13-24 (15:14-15:30) and 7-18-24 (8:08 a- 8:10 a) 2. The facility did not complete drills for each shift. Staff #1 acknowledged the drills were not completed for each shift in a quarter.
Plan of Correction:	The Environmental Service Director or designee will conduct every 6 months, on each shift, emergency evacuation drills. The Environmental Service Director or designee will conduct audits of required drills monthly. The Executive Director will review in the Quality Assurance Meeting Quarterly. In compliance as of January 31, 2025
Standard #:	22VAC40-73-970-E
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure the record of the required fire and emergency evacuation drills included all required information. Evidence: 1. On 12-26-24, the fire drills conducted on 12-12-24, 12-6-24, 12-4-24, 11-20-24 did not include the method used for notification of the drill, the number of residents participating; any special conditions simulated, the time it took to complete the drill, weather conditions and if any problems were encountered. 2. The fire drills conducted on 10-31-24, 9-27-24; 8-13-24 and 7-18-24 did not include the method used for notification of the drill and any special conditions simulated. 3. Staff #1 acknowledged the fire and evacuation drills conducted did not include all required information.
Plan of Correction:	The Environmental Service Director or designee will conduct fire drills and ensure all required information is listed per state regulations. The Environmental Service Director or designee will conduct audits of required drills monthly. The Executive Director will review in the Quality Assurance Meeting Quarterly. In compliance as of January 31, 2025
Standard #:	22VAC40-73-990-C
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the resident emergency and practice exercise was conducted with all staff currently on duty on each shift. Evidence: 1. On 12-26-24, the resident emergency- elopement drill conducted on 11-20-24 at 2:20 p.m. and 12-12-24 training conducted on 630a/ 245p and 330p did not include documentation of all staff currently on duty on each shift.
Plan of Correction:	The Environmental Service Director or Designee will ensure emergency and practice exercises with all staff on duty for each staff every shift and utilizing Tels system. Executive Director to review in Quality Assurance Meeting Quarterly.