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: May 12, 2023 and June 29, 2023

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 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

Technical Assistance:

CPR and First-aid certification must be through approved trainers

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/12/2023 from 8:42 am- 1:10 pm and 6/29/2023 from 10:48 am -5:47 pm 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: 48 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 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 Alyshia E. Walker, Licensing Inspector at 757- 670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-40-B
Description:	Based on the employee record review, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee. Evidence: The staff record provided to the licensing inspector at the time of inspection for staff #1 did not contain a Virginia State Police Criminal history check. Staff #1?s date of hire was documented as 11/28/2022.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-310-B
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure a documented interview between the administrator or designee responsible for admission and retention, the individual, and the legal representative, if any was in the record for a resident. Evidence: The files for residents #4 and #5 record did not include documentation of an interview.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-325-B
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure that a fall risk assessment was reviewed and updated after every fall. Evidence: 1. Resident # 4?s record included documentation of falls on 5/12/23 and 3/22/23. The resident record provided to the licensing inspector at the time of inspection did not contain fall assessments for those falls. 2. Resident # 5?s record included documentation of falls on 2/4/23, 4/8/23, 4/15/23, and 4/25/23. The resident record provided to the licensing inspector at the time of inspection did not contain fall assessments for those falls. 3. Staff members #2 acknowledged the record did not contain fall risk assessments for the above dates.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-350-B
Description:	Based on review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. Evidence: 1. Resident # 1 had an admission date of 7/23/22 and the resident?s record did not contain a Sex Offender Screening. 2. Resident # 5 had an admission date of 9/27/22 and the resident?s record did not contain a Sex Offender Screening. 3. Staff members #1 and #2 acknowledged the file did not contain the screening.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-390-B
Description:	Based upon documentation review, the facility failed to ensure at or prior to the time of admission, there shall be a written agreement signed by the resident. Evidence: Evidence: Resident #5 was admitted to the facility on 9/27/22 and there was no signed resident agreement in the file presented to the licensing inspection at the time of the inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-410-A
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure upon admission, it would provide an orientation for new residents and their legal representatives. Evidence: 1. Resident #4 was admitted to the facility on 2/162023 and the resident record did not contain verification the resident received orientation. 2. Resident #6 was admitted to the facility on 10/24/2022 and the resident record did not contain verification the resident received orientation. 3. Staff #1 and #2 acknowledged the resident?s file did not contain documentation the resident received orientation upon admission.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: Resident # 8?s record did not have documentation of a current ISP. The ISP in the record was signed 4/31022. The resident?s date of admit noted as 7/23/18.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-490-D
Description:	Based on the review of resident records, the facility failed to have a list of specific residents for whom the health care oversight was provided. Evidence: The last health care oversight was completed did not include a list of specific residents which the health care oversight was provided.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-550-G
Description:	Based on record review, the facility failed to ensure that the annual review of resident rights and responsibilities is filed in the resident?s record. Evidence: The record for Staff #4 did not contain a recent resident rights review which was reviewed and signed in the past year. The Resident Rights document in the staff file did not contain a date.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-650-C
Description:	There were following verbal order were obtained for resident #6 and there were no physician?s signature on the orders. Evidence: 1. There was a verbal order obtained on 4/21/23 for Zofran 8 mg. 2. There was a Verbal order was obtained on 5/2/23 for Omeprazole 20 mg for GERD. There was no physician?s signature on the documented verbal order. 3. Verbal orders were obtained on 5/19/23 for Keflex 500mg there was no physician?s signature on the documented verbal order.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-I
Description:	Based on documentation review, the facility failed to include all required documentation on the Medication Administration Record (MAR). Evidence: 1.The April 2023 MAR for Resident #1 did not contain the initials of the staff member who administered the resident?s Doxycycline 100 mg on 4/14 9pm, 4/19 9pm, and 4/21 9 am and there was no information documented on the back of the MAR. The staff member?s initials were missing for Resident #1?s Caltrate 600 on 4/19 9pm, Donepezil HCL 5mg on 4/19 9pm, and Mirtazapine 15 mg 4/19 9 pm and there was no information documented on the back of the MAR. April MAR for Resident # 8 did not contain initials for the folling medications and doses: Omeprazole 20 mg 4/9/23 at 9am Quetiapine 50 mg at 9am Vitamin d3 2000u 9 am Diclofenac Sodium 1% 4/4/23 5pm Diclofenac Sodium 1% 4/5/23 5pm Diclofenac Sodium 1% 4/9/23 9am
Plan of Correction:	Not available online. Contact Inspector for more information.