VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Regent of Newport News
741 Thimble Shoals
Newport news, VA 23601
(216) 378-2050

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: April 29, 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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/29/2024 1:50pm ? 8:00 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-380-B
Description:	Based on record reviewed the facility failed to ensure the personal and social information document was kept current. Evidence: 1. The Social Data information for Resident #1 was not complete.
Plan of Correction:	The Social Data Information for resident #1 has been reviewed and updated on 5/7/2024. The employees responsible for ensuring that resident Social Data Information forms are kept current have been educated of the regulations and Social Data Information form. The Executive Director or designee will complete random audits of all Social Data Information forms weekly for one month to ensure resident?s information is kept current. Audit results will be discussed weekly during the morning stand-up meeting.
Standard #:	22VAC40-73-450-E
Description:	Based on resident record reviewed, the facility failed to have the Individualized Service Plan (ISP) signed by the resident or his/her legal representative. Evidence: The ISP dated 4/20/2024 for Resident #1 did not contain a resident or legal representative signature.
Plan of Correction:	The resident ISP dated 4/20/2024 for resident #1 was signed by legal representative on 5/7/2024. The employees who are responsible for ensuring that resident ISPs are signed timely have been educated of regulation and 72 hour review expectation. All new admission ISPs shall be audited by the Executive Director or designee for signature from resident or legal representative for the next month. Audit results will be discussed during the morning stand-up meeting.
Standard #:	22VAC40-73-520-I
Description:	Based on observations made during a tour of the building, the facility failed to ensure the current month's activity schedule shall be posted in a conspicuous location in the facility. Evidence: 1. During the on-site inspection on 4/29/2024, there was no posted activities calendar. 2. Staff #1 and #3 acknowledged the activities calendar was not posted.
Plan of Correction:	The activity calendar was posted in a conspicuous place on 5/3/2024. Th Activity director has been educated on the regulation and the importance of having the calendar posted timely. Random audits will be conducted for 2 months to ensure that monthly calendar is posted timely. Audit results will be communicated monthly for two months during morning stand-up meetings.
Standard #:	22VAC40-73-610-B
Description:	Based on observation of facility postings the facility failed to ensure that menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents. Evidence: 1. There was no menu posted in the facility. 2. Staff #1, #2 and #3 acknowledged there was no menu posted in the facility.
Plan of Correction:	Menus for meals and snacks were posted in conspicuous place on 4/30/2024. The dietary manager has been educated on the regulation and importance of keeping an accurate meal menu and snack menu posted for current week. Random audits will be completed by the Executive Director or designee for 4 weeks. Audit results will be communicated once a week for four weeks during morning stand-up meetings.