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 5, 2025

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint An onsite complaint inspection was conducted on 9-10-24 (Ar 6:08 p.m/ Dep 9:30 p.m.); 9-23-24 (Ar 12:10 p.m./ Dep 12:55 p.m.) and 11-21-24 (Ar 09:10 a.m./Dep 14:55 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 9-10-24 regarding allegations in the area of resident care and related services-medication disposal. Number of residents present at the facility at the beginning of the inspection: 82 on 9-23-24 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 3 Number of interviews conducted with residents: Number of interviews conducted with staff: 5 Observations by licensing inspector: medication in dumpster behind dining facility Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were 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 #:	22VAC40-73-40-A
Complaint related:	Yes
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the licensee was in compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department, with relevant federal, state, and local laws; with other relevant regulations; and with the facilities own policies and procedures. Evidence: 1. On 9-10-24, the inspectors observed medications in the dumpster located behind the facility?s dining room. Staff #2 and #3 retrieved three large black trash bags from the dumpster. The contents of the bags consisted of over two-hundred sixty-four (264) bubble packets, bottles and containers of medications for forty-seven (47) residents including from pills, creams, inhalers, ear drops, patches, eyedrops, cough syrups, antidiarrheal, ointment, etc. that had not been destroyed per the facility?s medication management policy. The date of the medications ranged from 2-28-24 to 8-15-24. (See Photos) 2. The facility?s ?Department Medication Management Policy No: MED-001, Medication Administration, Effective 9/2017-Revised 10/2021?, section ?Discontinued Medication? noted medication staff will: ??remove the discontinued medication from the medication storage cart/cabinet and store in the designated secure area for drugs awaiting return/destruction. Unless otherwise prohibited under applicable state laws, non-controlled medications supplied in sealed containers may be returned, if unopened, to the issuing pharmacy. Medication destruction will be conducted per applicable state law. Two medication staff members (at least 1 licensed nurse must be present) will destroy all controlled medications. The Health and Wellness Director and/or designee will be responsible for destroying non-narcotic medications?Medication destruction will be recorded in the resident?s record/file and on a destruction log sheet, as required by state law?. 3. Staff #1 acknowledged staff #2?s last day at the facility was 09-11-2024. Staff #3?s record included documentation of further personnel action.
Plan of Correction:	Corrective Action(s): The facility updated and educated on the Medication Destruction/Permanent Discontinuance policy in 11/2024. An initial training session for med techs and nurses occurred on 11/17/2024. Documentation of this training is available in their personnel files. Inservice Log is attached to this POC. Systemic Change(s): The Medication Destruction/Permanent Discontinuance Policy (attached to this POC) outlines the proper procedures for the disposal and destruction of unused, expired, or discontinued medications to ensure safety and compliance with regulations. Newly hired staff who are qualified to administer medications will receive training on this policy from the Health and Wellness Director or designee during the facility's job specific onboarding. In addition, the policy will be uploaded into Relias, our learning management software, and auto-assigned to new Med Techs and Nurses to track and verify completion. The Health and Wellness Director or designee is responsible for reviewing and signing all clinical orientation checklists, acknowledging training on the policy and procedures and the completion of clinical orientation. Monitoring: The Executive Director will review job onboarding checklists for new Med Techs and Nurses x 180 days to verify they are complete and training has occurred. If compliant, will move to quarterly audits of new employee files as part of the Quality Assurance Meetings. This audit will be ongoing as part of the Quality Assurance Meetings and will include Med Techs and Nurses among the other associates. The facility has developed and implemented an audit tool designed to verify the proper disposal and destruction of medication as it occurs, with a weekly review by the Health and Wellness Director. This will occur for next 60 days. If in compliance, will discontinue audit tool. Initial training on this tool for all current staff qualified to administer medications occurred on 2/26/2025. Documentation of the training will be available in their personnel files. Inservice Log is attached to this POC.
Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure it had, kept current, a implemented a written plan for proper disposal of medication. Evidence: 1. On 9-10-24 during a complaint inspection regarding the improper disposal of medication, a request for a copy of the facility?s medication disposal policy was requested from staff #2 and #3. The facility?s, ?Department Medication Management Policy No: MED-014, Medication Drug Disposal? policy was provided to the inspectors. 2. On 9-25-24, staff #1 confirmed in an email that the medication disposal policy received was in fact the one (1) page document that was sent on 9-10-24.
Plan of Correction:	Corrective Action(s): The facility updated and educated on the Medication Destruction/Permanent Discontinuance policy in 11/2024. An initial training session for med techs and nurses occurred on 11/17/2024. Documentation of this training is available in their personnel files. Inservice Log is attached to this POC. Systemic Change(s): The Medication Destruction/Permanent Discontinuance Policy (attached to this POC) outlines the proper procedures for the disposal and destruction of unused, expired, or discontinued medications to ensure safety and compliance with regulations. Newly hired staff who are qualified to administer medications will receive training on this policy from the Health and Wellness Director or designee during the facility's job specific onboarding. In addition, the policy will be uploaded into Relias, our learning management software, and auto-assigned to new Med Techs and Nurses to track and verify completion. The Health and Wellness Director or designee is responsible for reviewing and signing all clinical orientation checklists, acknowledging training on the policy and procedures and the completion of clinical orientation. Monitoring: The Executive Director will review job onboarding checklists for new Med Techs and Nurses x 180 days to verify they are complete and training has occurred. If compliant, will move to quarterly audits of new employee files as part of the Quality Assurance Meetings. This audit will be ongoing as part of the Quality Assurance Meetings and will include Med Techs and Nurses among the other associates. The facility has developed and implemented an audit tool designed to verify the proper disposal and destruction of medication as it occurs, with a weekly review by the Health and Wellness Director. This will occur for next 60 days. If in compliance, will discontinue audit tool. Initial training on this tool for all current staff qualified to administer medications occurred on 2/26/2025. Documentation of the training will be available in their personnel files.