VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Charter Senior Living of Williamsburg
440 McLaws Circle
Williamsburg, VA 23185
(757) 221-0018

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

Inspection Date: June 21, 2022

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 ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

An unannounced renewal inspection was conducted on 06/21/2022 (11:30 am-3:30 pm) by two licensing representatives. At the time of the inspection there were 48 residents in care including 10 residents in memory care. Eight resident and four staff files were reviewed as well as other required documentation. All new personnel records since the last inspection wererequested for criminal history record reports compliance. See the violation notice for non-compliance. Lunch was observed, a musical in the garden activity was scheduled for later in the afternoon. Medication administration records were reviewed. Building and grounds were inspected. The Acknowledgement of Inspection form was signed and left at the facility with the Administrator on the date of the inspection. The evidence gathered during the renewal inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The applicant has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to maintain future compliance with applicable standard(s) or law. If the applicant 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. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Tamara Watkins, Licensing Inspector at (804) 662-7422 or by email at tamara.g.watkins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-40-A
Description:	Based on a review of the renewal application submitted and a State Corporation Commission business entity search, the facility failed to ensure compliance with relevant state laws. Evidence: 1. A renewal application was submitted on 6/21/2022 that listed the name of the LLC applying for the license as SNH/LTA Properties Trust. 2. A search of the Virginia State Corporation Commission found that this LLC Entity ID:C0000382 has an inactive/cancelled status in the State of Virginia since 12/31/2021. An active status is required to do business in the State of Virginia.
Plan of Correction:	1- Correction was done immediately and renewal application completed. 2- Renewal application will be followed annually. 3- Responsible party of SNH/LTA will be educated on VA state requirements. 4- Executive Director/designee will monitor renewal application annually.
Standard #:	22VAC40-73-110-1
Description:	Based on a review of background checks for staff hired since 11/1/2021, the facility failed to ensure that Staff meet the requirements specified in the Regulation for Background Checks for Assisted Living Facilities and Adult Day Care Centers (22VAC40-90). Evidence: 1.Section 63.2-1720 of the Code of Virginia requires all employees of assisted living facilities and adult day care centers, as defined by ? 63.2-100 of the Code of Virginia, to obtain a criminal history record report from the Department of State Police. 2. Regulation for Background Checks for Assisted Living Facilities and Adult Day Care Centers (22VAC40-90) defines a criminal history record report as ?either the criminal record clearance or the criminal history record issued by the Central Criminal Records Exchange, Department of State Police. 3. Licensing staff requested from the facility administrator (staff # 1) background checks for all staff hired since 11/1/2021. Staff # 1 provided a list of 75 staff with names, job titles and hired dates along with background checks. A review of the list provided found that 17 staff were hired from 11/1/2021 to present. Of the background checks provided by only staff # 1, 3 of the 17 staff had background checks from the Virginia State Police.
Plan of Correction:	1- Corrections were made as of January 2022 per an internal audit. Due to the delays at the VA Police department, the facility was not able to start using the updated account prior to March 2022. 2- Background checks will be reviewed and maintained by business office manager. Records will be maintained in staff files. 3- Business office manager will be re-educated on the state regulations and hiring process 4- The process will be reviewed monthly by the Executive Director. All findings will be corrected and reported to the QA committee for continued improvement and analysis.
Standard #:	22VAC40-73-250-C
Description:	Based on a review of four staff files, two of four staff files did not contain verification of current professional license, certification, registration, or completion of a required approved training course. Evidence: 1. Staff # 2 is documented as Med Tech- MC with a hire date of 5/19/2006. Licensing staff requested from Staff #1 verification of registration as a medication aide for staff # 2. Verification was not given or found in the file provided for review. 2. Staff # 3 is documented as Caregiver-Assisted Living with a hire date of 6/19/2019. Licensing staff requested from Staff #1 verification of qualifications as a direct care staff person for staff # 3. Verification was not given or found in the file provided for review.
Plan of Correction:	1-Immediate correction made on the day of the inspection. 2- Business office manager and health and wellness director re- educated on the professional certification requirements, updates, and approved trainings. 3- The process will be reviewed by the executive director/designee monthly for 3 months with an audit of 3 staff members. 4- All findings will be communicated to the BOM, staff members and reported to the QA committee for continued improvement and analysis.
Standard #:	22VAC40-73-260-C
Description:	Based on an inspection of the facility, the facility failed to have a listing of all staff who have current certification in first aid and/or CPR always posted and readily available to all staff. Evidence: A posting of staff who have current certification in first aid and/or CPR was not found during an inspection of the building and grounds on 6/21/2022 by two licensing inspectors. Facility staff acknowledged that it was not posted but available in the office.
Plan of Correction:	1-Corrections made immediately on the day of the inspection per the CPR training that was completed on 6/16/2022. 2- Business office manager (BOM) and health and wellness director (HWD) will monitor CPR certification needs and update the CPR list monthly. 3- BOM/HWD re-educated on CPR certificate updates and state requirements. Process will be monitored by the Executive Director/designee every 3 months. 4-All findings will be corrected and reported to the QA committee for continued improvement and analysis.
Standard #:	22VAC40-73-490-A-2
Description:	Based on a review of documentation requested and provided the facility failed to ensure that a health care oversight for assisted living residents was completed every three months. Evidence: The health care oversight provided by Staff #1 was dated 7/31/2021 and offered as the last oversight conducted. Staff #1 stated that regional staff were coming on 6/23/2022 to conduct health care oversights.
Plan of Correction:	1-Health care oversight will be completed immediately. 2- Health and wellness director re- educated on the requirements for health care oversight by the Executive Director. 3- The process will be reviewed by the Executive Director /Designee every 3 months with an audit to ensure the biannual health care oversight is in progress or completed. 4- All findings will be corrected and reported to the QA committee for continued improvement and analysis.
Standard #:	22VAC40-73-580-A
Description:	Based on information provided the facility failed to provide evidence of an annual health inspection by the Virginia Department of Health. Evidence: Facility staff provided a Food Establishment Inspection Report for review dated 1/15/2020 and a Food Establishment permit with a listed expiration dated1/31/2022.
Plan of Correction:	1-Facility?s renewal application was up to date on the day of the inspection. Food Establishment Permits confirmed by the department of health; however, they were not able to complete the inspection. 2- Dietary Services Director and Business office manager educated on the requirements. 3- Application follow up by the dietary services director/business office manager/ designee and recorded. 4 An annual audit will be conducted by the executive director and communication records will be reported to the QA committee for continued improvement and analysis.
Standard #:	22VAC40-73-970-A
Description:	Based on a review of documentation requested and provided the facility failed to ensure that fire drills were conducted on each shift in a quarter and not conducted in the same month. Evidence: The fire drills provided and reviewed were dated: 3/30/22 (11:15p), 4/14/2022 (10:50a). There were no drills provided for 5/2022.
Plan of Correction:	1-Records reviewed, and missing reports updated. 2- Fire drills scheduled per the regulations. 3- Environmental Services Director educated on the fire drill requirements and record keeping. 4- Process will be monitored monthly audits by the Executive Director. All findings will be reported to the QA committee for continued improvement and analysis.