Deficiencies per Year
24
18
12
6
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 7
May 12, 2025
Visit Reason
An unannounced complaint inspection was conducted due to a complaint received on 2025-04-17 regarding allegations in Resident Care and Related Services, Buildings and Grounds, and Staffing and Supervision.
Findings
The investigation supported some but not all allegations, identifying areas of non-compliance with standards and laws. Multiple medication-related deficiencies were found, including failure to report a major incident within 24 hours, administration of outdated medications, incomplete physician orders, improper medication administration, and unavailable PRN medications.
Complaint Details
The complaint was substantiated in part; some allegations were supported by evidence while others were not. The facility was found non-compliant in several medication management areas.
Deficiencies (7)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours any major incident negatively affecting a resident, specifically a medication error involving resident #5 receiving roommate's medication. |
| Facility administered outdated medications and failed to ensure timely refills. |
| Physician orders lacked required diagnosis or specific indications for medications. |
| Medications were not administered according to prescriber instructions, including improper measurement of liquid medication. |
| Medication Administration Records (MARs) did not include all required information such as diagnosis or specific conditions. |
| PRN medication orders did not include exact dosage information. |
| Medications ordered for PRN administration were not available, properly labeled, or properly stored at the facility. |
Report Facts
Number of residents present: 47
Number of resident records reviewed: 6
Number of resident interviews: 4
Number of staff interviews: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Acknowledged medication error and failure to notify licensing office; acknowledged physician orders lacked diagnosis; acknowledged PRN medication issues. | |
| Staff #3 | Acknowledged administration of outdated medication and improper medication measurement; unable to locate PRN Lidocaine patch. |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 2
Mar 5, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2024-09-10 regarding allegations related to resident care and medication disposal at the facility.
Findings
The investigation confirmed non-compliance with regulations concerning medication disposal, including discovery of improperly discarded medications in the dumpster behind the dining facility. Violations were issued related to failure to comply with licensing regulations and failure to maintain a proper medication disposal plan.
Complaint Details
The complaint was substantiated. Evidence included observation of medications discarded improperly and review of facility policies and staff interviews confirming non-compliance with medication disposal regulations.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license, including improper disposal of medications found in dumpster. |
| Facility failed to ensure it had a current, implemented written plan for proper disposal of medication. |
Report Facts
Residents present: 82
Resident records reviewed: 5
Staff records reviewed: 3
Staff interviews conducted: 5
Medications found in dumpster: 264
Residents affected by discarded medications: 47
Inspection Report
Renewal
Census: 76
Deficiencies: 16
Dec 23, 2024
Visit Reason
An unannounced mandated renewal inspection was conducted on December 23 and 26, 2024, to assess compliance with applicable standards and laws for facility licensing renewal.
Findings
The inspection found multiple violations related to resident admission criteria, staff orientation, physical examination documentation, resident information accuracy, individualized service plans, medication storage and administration, safety signage, hazardous materials control, building maintenance, glare reduction, and fire and emergency evacuation drills. Plans of correction were provided with compliance dates ranging from January to February 2025.
Deficiencies (16)
| Description |
|---|
| Facility failed to ensure residents admitted to the safe, secure environment had a cognitive impairment due to a primary psychiatric diagnosis of dementia. |
| Staff orientation did not include documentation of the facility's organizational structure. |
| Physical examination forms did not include all required information, including correct ambulatory classification. |
| Resident personal and social information was not kept current. |
| Resident individualized service plans did not include all assessed needs. |
| Resident rights and responsibilities were not reviewed annually as documented. |
| Menus for meals and snacks for the current week were not posted in a conspicuous area. |
| Medications were not stored in a locked container/area consistent with standards of practice. |
| Resident medication was administered outside the facility's standard dosing schedule (not within one hour before or after). |
| Facility failed to post 'No Smoking-Oxygen in Use' signs in rooms where oxygen was in use. |
| Hazardous materials were found in an unlocked and accessible area. |
| Interior of the building was not maintained in good repair, including scuffed walls and paint tearing. |
| Glare was not minimized in resident rooms; overhead lights lacked coverings. |
| Fire and emergency evacuation drills were not conducted with required frequency and participation across all shifts. |
| Records of fire and emergency evacuation drills did not include all required information such as notification method, resident participation, special conditions, and drill duration. |
| Resident emergency and practice exercises were not conducted with all staff currently on duty on each shift. |
Report Facts
Residents present: 76
Resident records reviewed: 7
Staff records reviewed: 3
Resident interviews conducted: 2
Staff interviews conducted: 9
Fire drills noted: 8
Inspection Report
Monitoring
Census: 81
Deficiencies: 9
Aug 15, 2024
Visit Reason
An on-site monitoring inspection was conducted to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations including failure to retain written acknowledgements of disclosures, incomplete tuberculosis risk assessments for staff, outdated postings of staff in charge, missing signed written assurances of licensing, physical examinations not within required timeframes, incomplete individualized service plans, building maintenance issues, failure to post the most recent inspection findings, and incomplete criminal background checks for staff.
Deficiencies (9)
| Description |
|---|
| Facility failed to ensure written acknowledgement of receipt of disclosure by resident or legal representative was retained in the resident's record. |
| Facility failed to ensure each staff submitted tuberculosis risk assessment within required timeframe. |
| Facility failed to ensure posting for the name of the current on-site person in charge was current. |
| Facility failed to ensure administrator provided written assurance of appropriate license at time of admission. |
| Facility failed to ensure physical examination was within 30 days of resident's admission. |
| Facility failed to ensure individualized service plan included all assessed needs. |
| Facility failed to ensure interior and exterior of building was maintained in good repair and kept clean and free of rubbish. |
| Facility failed to ensure findings of the most recent inspection were posted. |
| Facility failed to ensure criminal history record report was obtained on or prior to the 30th day of employment for each employee. |
Report Facts
Number of residents present: 81
Number of resident records reviewed: 7
Number of staff records reviewed: 3
Number of resident interviews conducted: 3
Number of staff interviews conducted: 10
Inspection Report
Renewal
Census: 81
Deficiencies: 21
May 6, 2024
Visit Reason
An unannounced on-site renewal inspection was conducted on May 6 and May 7, 2024, to assess compliance with applicable standards and laws for facility license renewal.
Findings
The inspection identified multiple areas of non-compliance including staff training deficiencies, incomplete or missing documentation in resident and staff records, expired certifications, medication administration issues, facility maintenance concerns, and emergency preparedness shortcomings. Violations were documented and a plan of correction was requested.
Deficiencies (21)
| Description |
|---|
| Facility failed to ensure staff had training relevant to the population in care, including oxygen training. |
| Staff records lacked required health information, including tuberculosis risk assessments. |
| Staff did not maintain current certification in adult first aid and CPR. |
| Listing of staff with current first aid or CPR certification was not kept updated. |
| Written work schedules did not include full names and job classifications of all staff. |
| No documented interview between administrator/designee and resident/legal representative for admission and retention decisions. |
| Facility admitted or retained individuals with prohibited conditions or care needs without supporting documentation. |
| Resident personal and social information was not kept updated. |
| Resident orientation documents were not signed and dated by resident or legal representative. |
| Resident individualized service plans (ISP) did not include all assessed needs or were not signed and dated properly. |
| Facility failed to maintain compliance with Department of Health inspection requirements. |
| Pharmacy reference books for nurses were outdated (older than two years). |
| Medical supplies and equipment, such as glucometers, were not properly labeled. |
| Medication administration records (MAR) lacked required information such as diagnosis or condition for medications. |
| Medications ordered for PRN administration were not available, properly labeled, or properly stored. |
| Interior of buildings, including ceilings, were not maintained in good condition. |
| Emergency preparedness plan was not reviewed and signed by all staff on all shifts semi-annually. |
| Fire and emergency evacuation drawings did not include all required information. |
| Emergency telephone numbers, including Poison Control Center number, were not posted near telephones. |
| Staff did not participate in required emergency procedure exercises at least every six months. |
| Employees worked in direct contact with residents without completed background checks. |
Report Facts
Inspection duration: 2
Facility census: 81
Plan of correction completion dates: Jun 10, 2024
Audit completion dates: May 31, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Contact person for questions about the inspection |
| Darunda Flint | Inspector | Current inspector conducting the inspection |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 2
Apr 3, 2024
Visit Reason
An unannounced complaint inspection was conducted on April 3, 2024, following a complaint received on February 13, 2024, regarding allegations in the areas of resident care and related services.
Findings
The investigation did not support the allegations of non-compliance related to the complaint; however, violations not related to the complaint were identified during the inspection. These violations involved failure to document justification for placement of a resident with serious cognitive impairment in a safe, secure unit and failure to ensure psychotropic treatment plans included prescriber date and signature.
Complaint Details
Complaint investigation was conducted based on a complaint received on 2024-02-13 regarding resident care and related services. The evidence did not support the allegations of non-compliance with standards or law.
Deficiencies (2)
| Description |
|---|
| Failed to ensure prior to admitting a resident with serious cognitive impairment due to dementia to a safe, secure environment, the licensee or designee documented justification for placement in the special care unit. |
| Failed to ensure psychotropic treatment plans included the date and signature of the prescriber for a resident prescribed psychotropic medications. |
Report Facts
Number of residents present: 86
Number of resident records reviewed: 3
Number of staff interviews conducted: 3
Inspection Report
Monitoring
Deficiencies: 3
Aug 31, 2023
Visit Reason
An on-site IPOC Monitoring Inspection was conducted to assess compliance with applicable standards and laws at Charter Senior Living of Newport News.
Findings
The inspection found non-compliance with several standards including missing sworn disclosure statements in employee records, incomplete resident physical examination documentation, and discrepancies in the preliminary plan of care regarding assessed needs.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure an employee record included documentation of a sworn disclosure statement. |
| Licensee/provider did not provide plan of correction by due date and failed to ensure the resident's physical examination document included all required information. |
| Facility failed to ensure the preliminary plan of care included all assessed needs. |
Report Facts
Inspection dates: 2
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Aug 31, 2023
Visit Reason
An on-site complaint inspection was conducted on 2023-08-31 following a complaint received on 2023-08-30 regarding allegations in resident care, medication, and ADL care (bathing and dressing).
Findings
The investigation did not support the allegation of non-compliance with standards or law. However, violations unrelated to the complaint were identified during the investigation, including failure to ensure the annual individualized service plan included all assessed needs.
Complaint Details
Complaint related to allegations in resident care, medication, and ADL care (bathing and dressing). The evidence gathered did not support the allegation of non-compliance with standards or law.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the annual individualized service plan (ISP) included all assessed needs, such as hospice services and redirection methods for a disoriented resident. |
Report Facts
Number of residents present: 73
Number of resident records reviewed: 2
Number of resident interviews: 2
Number of staff interviews: 4
Inspection Report
Renewal
Census: 81
Deficiencies: 14
Jun 30, 2023
Visit Reason
The inspection was an on-site Renewal Inspection conducted over three days (June 5, 7, and 9, 2023) to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection found multiple violations related to staff training hours, infection control training, posting of first aid/CPR staff listings, resident admission documentation, individualized service plans, medication administration records, first aid kit maintenance, and employee criminal history record checks. The facility was found non-compliant with several regulatory standards and was issued a violation notice.
Deficiencies (14)
| Description |
|---|
| Facility failed to ensure all direct care staff attended at least 18 hours of training annually. |
| Facility failed to ensure at least two hours of training focused on infection control and prevention. |
| Facility failed to post a current listing of staff with first aid or CPR certification. |
| Facility failed to provide written assurance of appropriate licensing to residents prior to admission. |
| Facility failed to admit or retain individuals with prohibitive conditions without supporting documentation for psychotropic medications treatment plans. |
| Facility failed to ensure tuberculosis screening documentation was completed prior to admission for one resident. |
| Facility failed to ascertain and document sex offender status prior to admission for one resident. |
| Facility failed to keep resident personal and social information documents current. |
| Facility failed to ensure comprehensive individualized service plans included all assessed needs. |
| Facility failed to ensure individualized service plans were reviewed and updated at least annually and as needed for significant changes. |
| Facility failed to ensure a written agreement for residents consuming meals in their rooms was signed and filed. |
| Facility failed to ensure medication administration records included all required information. |
| Facility failed to ensure first aid kits were checked monthly and fully stocked with non-expired items. |
| Facility failed to ensure criminal history record reports were obtained on or prior to the 30th day of employment for all employees. |
Report Facts
Annual training hours: 16.25
Infection control training hours: 0.75
Infection control training hours: 0.5
Staff members reviewed: 59
Staff with CRC processing delay: 9
Staff without CRC: 16
Inspection days: 3
Census: 81
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 6
Mar 21, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2023-03-09 regarding allegations in the areas of resident care and related services, buildings and grounds.
Findings
The investigation supported some but not all allegations of non-compliance. Several violations were identified including failure to report major incidents within 24 hours, lack of required documentation for private duty personnel, missing annual reassessments, incomplete individualized service plans, and maintenance issues such as stained carpeting.
Complaint Details
The complaint investigation was triggered by allegations received on 2023-03-09 concerning resident care and building conditions. The evidence supported some allegations, resulting in a violation notice. The complaint was partially substantiated.
Deficiencies (6)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident. |
| Facility failed to ensure required documents for private duty personnel hired by families providing direct care or companion services. |
| Facility failed to ensure annual reassessment or reassessment due to significant change using the Uniform Assessment Instrument (UAI). |
| Individualized service plan (ISP) did not include all required information for one of five residents. |
| Updated individualized service plan (ISP) failed to include all resident needs for three residents. |
| Interior of the building was not maintained in good repair and was not kept clean and free of rubbish; carpet in resident room was stained. |
Report Facts
Number of residents present: 85
Number of resident records reviewed: 5
Number of staff records reviewed: 0
Number of resident interviews conducted: 4
Number of staff interviews conducted: 7
Incident reporting timeframe: 24
Carpet replacement scheduled by: May 5, 2023
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 19
Oct 14, 2022
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2022-09-13 regarding allegations in resident care, buildings and grounds, staffing, and food/nutrition.
Findings
The investigation supported some but not all allegations of non-compliance. Multiple deficiencies were found related to resident placement documentation, staff training, record keeping, medication management, facility maintenance, and pest control.
Complaint Details
The complaint investigation was substantiated in part. The complaint involved allegations in resident care, buildings and grounds, staffing, and food/nutrition. Some allegations were supported by evidence while others were not.
Deficiencies (19)
| Description |
|---|
| Failed to ensure written justification for placement of a resident with serious cognitive impairment in the secure unit was documented. |
| Failed to ensure direct care staff received required 10 hours of cognitive impairment training within four months of employment. |
| Failed to retain written acknowledgement of receipt of disclosure by resident or legal representative. |
| Failed to document orientation and training within first seven working days of employment for staff. |
| Failed to document significant happenings or problems experienced by residents in the facility communication book. |
| Failed to admit or retain individuals with prohibitive conditions without supporting documentation, including treatment plans for psychotropic medications. |
| Failed to complete fall risk rating after each fall for a resident. |
| Failed to ascertain and document sex offender status prior to admission for residents with length of stay greater than three days. |
| Failed to provide and document orientation for new residents and their legal representatives upon admission. |
| Failed to ensure annual reassessment and reassessment due to significant change using the uniform assessment instrument (UAI). |
| Failed to complete comprehensive individualized service plan (ISP) within 30 days after admission including all required assessed needs. |
| Failed to coordinate hospice care with licensed hospice organization and include hospice services in ISP. |
| Failed to ensure ISP was signed and dated by licensee/administrator/designee and resident or legal representative. |
| Failed to review and update ISP at least once every 12 months and as needed for significant change in condition. |
| Failed to follow medication management plan to ensure timely filling and refilling of prescription and over-the-counter medications. |
| Medication administration records (MARs) did not include initials of direct care staff administering medications. |
| Failed to maintain interior of building in good repair and keep clean and free of rubbish; ceiling repairs and water leaks noted. |
| Failed to keep building free of infestations of insects and vermin; bedbug issues documented. |
| Failed to obtain criminal history record report on or prior to 30th day of employment for staff. |
Report Facts
Residents present: 82
Resident records reviewed: 4
Staff records reviewed: 5
Staff interviews conducted: 0
Staff #4 cognitive training hours: 6
Medication unavailability days: 5
Medication unavailability days: 10
Fall dates without risk rating: 5
Pest control treatment dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Current Inspector | Named as the licensing inspector conducting the inspection |
| Willie Barnes | Licensing Inspector | Contact person for questions about VDSS Licensing Programs |
| Staff #1 | Acknowledged multiple deficiencies including missing documentation and facility conditions | |
| Staff #2 | Acknowledged missing documentation in resident records and MARs | |
| Staff #4 | Acknowledged missing cognitive training documentation | |
| Staff #7 | Acknowledged missing criminal background check documentation | |
| Staff #9 | Acknowledged missing orientation and training documentation | |
| HWD | Responsible for audits and corrective actions | |
| RCC | Responsible for audits and corrective actions | |
| BOM | Responsible for monitoring staff training compliance |
Inspection Report
Renewal
Deficiencies: 7
Mar 29, 2022
Visit Reason
A representative with the Division of Licensing conducted an unannounced, mandated renewal inspection on 03/29/2022 to review staff and resident records, tour the facility, and assess compliance with applicable regulations.
Findings
The inspection identified multiple violations including failure to ensure tuberculosis risk assessments for staff, outdated fall risk assessments for residents, incomplete or outdated individualized service plans, lack of annual review of resident rights with staff, and failure to provide evidence of an annual fire inspection.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure each staff person submitted tuberculosis risk assessment prior to first day of work. |
| Facility failed to ensure the fall risk rating was reviewed and updated annually for residents. |
| Facility failed to ensure all residents were assessed face to face annually using the uniform assessment instrument. |
| Facility failed to complete a comprehensive individualized service plan within 30 days after admission. |
| Facility failed to ensure individualized service plans were reviewed and updated at least annually and as needed. |
| Facility failed to ensure resident rights and responsibilities were reviewed annually with each staff person. |
| Facility failed to provide evidence of compliance with the Virginia Statewide Fire Prevention Code via annual fire inspection report. |
Inspection Report
Monitoring
Deficiencies: 0
Jun 7, 2021
Visit Reason
A monitoring inspection was initiated and conducted using an alternate remote protocol due to a state of emergency health pandemic declared by the Governor of Virginia.
Findings
The inspection reviewed resident and staff records submitted by the facility and determined no violations with applicable standards or law. No violations were issued.
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