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 14, 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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 5/14/2024 and 5/16/2024 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: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: The Licensing Inspector observed medication passes, inspected resident rooms, pulled call bell, and took water temperatures. 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. T he 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 #:	22VAC40-73-50-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it prepared and provided a statement to the prospective resident and the legal representative, if any, that disclosed information about the facility. Written acknowledgement of this form shall be retained in the resident?s record. Evidence: The resident record for Resident #4 did not have documentation a disclosure statement had been provided to the resident before admission.
Plan of Correction:	The BOM (Business Office Manager) and/or Designee will audit all current Resident?s Files to ensure that the Disclosure statement was obtained prior to Admission. Going forward the BOM (Business Office Manager) and/or Designee will audit the incoming admission paperwork, using the move-in checklist, to ensure this disclosure statement is included on every new Admission. Any missing items from the move in checklist will be reported to the Executive Director (ED) and reviewed quarterly at our Quality Assurance (QA) meeting.
Standard #:	22VAC40-73-210-B
Description:	Based on the on-site record review and staff interview the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually. (Exception: Direct care staff who are licensed health care professions or certified nurse aides shall attend at least 12 hours of annual training). Evidence: 1. The record for Staff #4, a certified nurse aide, did not include documentation of 12 hours of annual training. 2. The record for Staff #2, a certified nurse aide did not include documentation of 12 hours of annual training.
Plan of Correction:	The BOM (Business Office Manager) and/or Designee will review each staff member?s training file to ensure that their monthly Relias training courses are up to date. Going forward, the BOM (Business Office Manager) and/or Designee will audit at least 10% of the staff?s training records monthly to ensure that the required 12 hours of annual training are completed for each staff member. Any incomplete training courses will be reported to the Executive Director (ED) and reviewed quarterly during our QA meeting.
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records the facility failed to ensure that each staff person submit the results of a tuberculosis (TB) risk assessment on or within seven days prior to the first day of work at the facility and that each staff person submit the results of a risk assessment annually. Evidence: The file for Staff #5 did not contain an annually completed TB risk assessment as the assessment form provided at the time of inspection was dated 7/5/2022.
Plan of Correction:	The BOM (Business Office Manager) and/or Designee will audit each staff member?s file to ensure that their TB risk assessment form is in file, completed, and not expired. Going forward the BOM (Business Office Manager) and/or Designee will audit at least 10% of the Team Member files monthly to ensure that no staff member?s TB risk assessment form is out of compliance. Any missing TB paperwork will be reported to the ED and reviewed quarterly during our QA meeting.
Standard #:	22VAC40-73-260-A
Description:	Based on a review of staff records the facility failed to ensure that each direct care staff member maintained current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: The employee file for Staff #5 contained a CPR certification card from National CPRFoundation which is not an approved provider as listed in 22VAC40-73-260-A.
Plan of Correction:	The BOM (Business Office Manager) and/or Designee did initial audit on all team member files to ensure that their CPR Certification is up to date and from an approved provider. Going forward, the BOM (Business Office Manager) and/or Designee will use a tickler system that notifies the community when a staff member?s license is nearing expiration. The Business Office Manager (BOM) and/or Designee will coordinate to have the American Heart Association CPR/First Aid trainings on a monthly basis to ensure that each staff member obtains the required CPR/First Aid Certifications. Any expired certifications will be reported to the ED and reviewed quarterly during our QA meeting.
Standard #:	22VAC40-73-310-D
Description:	Based on record review and staff interviewed, the facility failed to ensure prior to admission of a resident, the facility administrator provided written assurance to the resident that the facility has the appropriate license to meet the care needs at the time of admission. Acknowledgement of this document should be signed by the resident or a legal representative and kept in the resident?s record. Evidence: Resident #4 was admitted on 4/23/2024, the resident?s file did not contain documentation of written assurance being provided to the resident or responsible party.
Plan of Correction:	The Business Office Manager (BOM) and/or Designee will audit each resident?s file to ensure that the Written Assurance was obtained prior to Admission. Going forward the BOM (Business Office Manager) and/or Designee will audit the incoming admission paperwork, using the admission checklist, to ensure this document is included on every new Admission. Any missing paperwork will be reported to the ED and reviewed quarterly at our QA meeting.
Standard #:	22VAC40-73-410-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the record included an acknowledgement of the resident having received an orientation and the acknowledgment signed and dated by the resident, and as appropriate legal representative and kept in the resident?s record. Evidence: Resident #10?s record did not include documentation of an orientation for new residents which included information regarding mealtimes, the use of the call system, and the emergency response procedures.
Plan of Correction:	The Business Office Manager (BOM ) and/or Designee will audit each current resident?s chart to ensure that the orientation checklist is in place. Going forward, the BOM and/or Designee will ensure, using the new admission checklist, that each new Resident and/or Legal Representative has completed an Orientation to the community, and it is documented in the Resident Chart within the Business Office. The BOM and/or Designee will audit 10% of resident charts monthly to ensure that all orientation checklists are in place. Any missing paperwork will be reported to the ED and reviewed quarterly at our QA meeting.
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review and interview with staff, the facility failed to have the ISP signed and dated by the licensee, administrator, or designee and by the resident or his legal representative. Evidence: 1. Resident #5 has an ISP dated 8/25/2023. There were no signatures on the ISP of the licensee, administrator, or designee and the resident or his legal representative. 2. Resident #6 has an ISP not dated 8/15/2023 and the ISP did not include a signature of the resident or his legal representative.
Plan of Correction:	The HWD and/or Designee has Audited all existing Resident Healthcare records to ensure that all Individualized Service Plans have appropriate signatures from the resident or his/her legal representative. Going forward the HWD and/or Designee will audit 10% of the residents? ISPs monthly to ensure that all ISPs have appropriate dates and/or signatures. The HWD and/or Designee will coordinate in the weekly Wednesday Care Plan meeting which residents are due for their next assessment and ensure it is completed in a timely manner and has appropriate signatures and dates. Any ISPs without proper signatures and/or dates will be reported to the ED and reviewed quarterly at our QA meeting.
Standard #:	22VAC40-73-580-A
Description:	Based on record review, the facility failed to ensure when any portion of an assisted living facility is subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulations, as evidenced by an initial and subsequent annual reports from the Virginia Department of Health. Evidence: 1. During the on-site inspection the most recent documented health inspection was dated 12/5/2023. 2. Staff #1 acknowledged the facility?s health inspection was not current.
Plan of Correction:	Submitted to licensing inspector email from February 2024 where administrator requested Food Establishment License and Full Inspection Report from Inspection completed on 12/5/24. VDH sent community email stating that they were in good standing but due to staffing challenges, there was a delay in sending full report and sending license.
Standard #:	22VAC40-73-640-B
Description:	Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes. Evidence: 1. A review of the Narcotic Inventory Count Verification forms for Hall 1 and Hall 4 documented staff failed to ensure counts of all controlled substances occurred between oncoming staff and off going staff. 2. Staff members #2 and #5 acknowledged the forms did not document narcotic medication counts were conducted during the change of each shift.
Plan of Correction:	The HWD and/or Designee will provide an in-service training to all medication aides on the narcotic policy by 7/31/24. The HWD (Health and Wellness Director) and/or Designee ensure that narcotic medication counts are conducted at the change of each shift and are to be monitored weekly by the HWD and/or Designee going forward. The narcotic inventory count verification forms will be signed by each off going and oncoming staff member for all controlled substances. Any missing signatures will be reported to the ED and reviewed quarterly at our QA meeting.
Standard #:	22VAC40-73-640-D
Description:	Based on observation and staff interviewed, the facility failed to ensure the pharmacy reference book, drug guide, or medication handbook was no more than two years old as reference for staff who administer medications. Evidence: 1. The pharmacy drug guide on-site on 5/14/2024 was dated 2019. 2. Staff #2 acknowledged the pharmacy reference book was not dated within the past two years.
Plan of Correction:	The HWD and/or Designee has Audited all medication carts to ensure that all pharmacy reference books are current or within the past two years. Going forward the HWD and/or RCC (Resident Care Coordinator) and/or Designee will complete medication cart audit form for each med cart weekly to include ensuring the most up-to-date pharmacy reference books are current and inside the med cart. Any missing items will be reported to the ED and reviewed quarterly at our QA meeting.
Standard #:	22VAC40-73-680-D
Description:	Based on observations made during the review of the resident record, the facility failed to administer medications in accordance with the physician?s or other prescriber?s instructions. Evidence: Resident #5 was prescribed Omeprazole 20mg tablet for Gerd to be administered daily before breakfast. During the medication observation pass on 5/14/2024 at 9:05 am, the resident was administered the medication. The resident was returning from eating breakfast.
Plan of Correction:	The HWD and/or Designee will provide an in-service training for all medication aides on the medication administration policy by 07/31/24. The HWD and/or Designee will conduct a competency test for all medication aides upon hire and any time a medication error has been identified. The HWD (Health and Wellness Director) and/or Designee will review medication pass report and med exception report to ensure all medications are administered per physicians' orders. Any errors will be reported to the ED and reviewed at our quarterly QA meeting.
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the first aid kits were checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. Evidence: On 5/14/2024 during the inspection of the First-Aid kit for the building, the Triple Antibiotic Ointment had an expiration date of 5/2021 and the hand sanitizer had an expiration date of 9/2023.
Plan of Correction:	The HWD and/or Designee has replaced all first aid kits in the community and on the community bus. All required items inside the first aid kit have been replaced. HWD or Designee will be reviewed monthly utilizing checklist to ensure there are no contents that are missing or expired. The ED will be notified of any expired or missing items and review quarterly at QA meeting.