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.
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.