VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Charter Senior Living of Fredericksburg
20 Heartfields Lane
Fredericksburg, VA 22405
(540) 373-8800

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: June 24, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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

Comments:

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/24/24, 10:15 a to 1:25 p 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: 65 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: file documentation, required postings, medication pass, facility maintenance, staff/resident interaction Additional Comments/Discussion: The inspection was conducted by two licensing inspectors. 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 Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at Yvonne.randolph@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1100-A
Description:	Based on a review of files for three residents in the safe, secure environment, it was determined that the facility did not ensure that prior to placing a resident with a serious cognitive impairment due to a primary diagnosis of dementia in a safe, secure environment, the facility shall document that written approval was obtained following the order of priority: Evidence: 1. Documentation that the order of priority was followed was not found during a review of the files for residents # 3, and # 6. 2. The Approval for resident # 5 was obtained after admission to the safe, secure environment. Staff # 1 reported that the resident was admitted and assessed on 6/8/22. The approval was dated 2/4/24. 3. Staff # 1 reviewed the files and was unable to provide documentation of compliance.
Plan of Correction:	1.Health and Wellness Director or Designee will audit all special care unit resident files to ensure Approval for Placement in Special Care Unit form is signed prior to admission in SCU by 7/31/24. 2.Any resident files missing Approval for Placement in Special Care Unit form or missing signature of resident representative on form will be reported to Executive Director and resident?s representative to be completed. 3.Health and Wellness Director / designee will utilize move-in checklist for all future admissions and transfer of resident from Assisted living to SCU to ensure Approval for Placement in Special Care unit forms are signed prior to admission/transfer to SCU. 4.Health and Wellness Director / designee will audit at least 10% of resident files monthly for a period of six months to ensure compliance in accordance with the regulation. The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff files, it was determined that the facility did not ensure that each staff person or household member required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis 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. The results of an annual risk assessment for tuberculosis was not documented in the files of staff # 2. The screening form for staff # 2 did not have the results or a date. 2. The results of an annual risk assessment for tuberculosis was not documented in the files of staff # 3. The screening form for staff # 3 did not have a date. 3. The results of an annual risk assessment for tuberculosis was not documented in the files of staff # 4. The last screening for staff # 4 was dated 2-21-23.
Plan of Correction:	1.Staff records updated with the annual TB risk assessment. 2.All staff records to be audited by the Business office Manager or Designee to ensure the annual TB risk assessments are complete by 7/31/24. 3.Any personnel files found to be missing required annual TB risk assessments will be reported to ED for staff completion. 4.The Business Office Manager / designee will audit at least 10% of staff files monthly. The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.
Standard #:	22VAC40-73-490-A-2
Description:	Based on a review of file documentation, it was determined that the facility did not ensure that health care oversight was provided at least every three months for residents at the assisted living level of care, by a health care professional practicing within the scope of his profession. Evidence: 1. Documentation of health care oversight was requested of staff # 1. The last documented health care oversight was completed on 2/3/24. 2. Staff # 1 was unable to provide any oversight completed after 2/3/24.
Plan of Correction:	1.Health and Wellness Director / designee will schedule health care oversight to be completed by 7/31/24. 2.Health and Wellness Director / designee will schedule health care oversights quarterly. 3.Health and Wellness Director / designee will audit health care oversights quarterly to ensure compliance in accordance with the regulation. The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.