Inspection Reports for Brookdale Chambrel Williamsburg
3800 Treyburn Drive,Williamsburg, VA, VA
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Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 6, 2025
Visit Reason
An on-site inspection was conducted related to a complaint received by VDSS Division of Licensing on October 24, 2025, regarding allegations in the areas of personnel and resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. Residents were observed interacting appropriately with staff and each other, and were properly dressed and groomed.
Complaint Details
Complaint received on October 24, 2025, regarding personnel and resident care; investigation found no substantiation of non-compliance.
Report Facts
Resident records reviewed: 1
Resident interviews conducted: 3
Staff interviews conducted: 1
Inspection Report
Renewal
Census: 135
Deficiencies: 0
Oct 6, 2025
Visit Reason
The inspection was a renewal inspection conducted to evaluate compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. Observations included appropriate medication administration, proper resident grooming, and safe building conditions.
Report Facts
Resident records reviewed: 7
Staff records reviewed: 4
Staff interviews conducted: 6
Inspection Report
Renewal
Census: 128
Deficiencies: 4
Sep 24, 2024
Visit Reason
The inspection was a renewal inspection conducted on September 24 and 25, 2024, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations related to individualized service plans, two-hour rounding documentation, emergency drill participation, and criminal history record reports for staff. The facility was found non-compliant and issued a violation notice with opportunities to submit plans of correction.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure individualized service plans included descriptions of identified needs and dates based on assessments and other sources. |
| Facility failed to document two-hour rounding for residents with inability to use signaling devices in a secure unit. |
| Facility failed to document that all staff on each shift participated in emergency procedure drills at least once every six months. |
| Facility failed to obtain a criminal history record report on or prior to the 30th day of employment for a staff member. |
Report Facts
Number of residents present: 128
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of resident interviews conducted: 4
Number of staff interviews conducted: 4
Percentage of residents' ISPs audited weekly: 10
Percentage of two-hour rounding logs audited weekly: 10
Percentage of newly hired staff records audited weekly: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions about the VDSS Licensing Programs |
| Health and Wellness Director | Health and Wellness Director (HWD) | Named in plan of correction for retraining and auditing related to individualized service plans and two-hour rounding |
| Executive Director | Executive Director (ED) | Named in plan of correction for retraining and auditing related to individualized service plans, two-hour rounding, emergency drills, and staff record audits |
| Maintenance Director | Maintenance Director | Named in plan of correction for conducting resident emergency drills |
| HR Manager | HR Manager | Named in plan of correction for retraining and auditing related to criminal history record reports |
Inspection Report
Complaint Investigation
Census: 132
Deficiencies: 0
Aug 8, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-07-16 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not find evidence to support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly.
Complaint Details
Complaint received on 2024-07-16 regarding Resident Care and Related Services; evidence did not support allegations of non-compliance.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Census: 148
Deficiencies: 1
May 23, 2024
Visit Reason
The inspection was a monitoring visit conducted on May 23, 2024, including review of personnel, admission, retention and discharge of residents, and resident care and related services. The visit was not complaint-related but included investigation of two self-reported incidents received earlier in May 2024.
Findings
The investigation did not support the self-reports of non-compliance; however, violations unrelated to the self-reports were identified. One deficiency was cited related to the individualized service plan not accurately reflecting medication management for a resident, which has since been corrected and will be monitored through retraining and audits.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the comprehensive individualized service plan included a description of identified needs and date identified based on the UAI and admission physical examination, specifically the medication management plan for Resident #3 was inaccurate. |
Report Facts
Number of residents present: 148
Number of resident records reviewed: 3
Number of staff records reviewed: 1
Number of resident interviews conducted: 1
Number of staff interviews conducted: 3
Percentage of ISP audits: 10
Timeframe for retraining: 8
Timeframe for ISP correction: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
| Coy Stevenson | Current Inspector | Inspector on-site during the inspection |
| Health and Wellness Director | Corrected the individualized service plan for Resident #3 and responsible for auditing ISPs | |
| Executive Director | Will retrain licensed nursing associates on documentation process |
Inspection Report
Monitoring
Census: 145
Deficiencies: 0
May 2, 2024
Visit Reason
The inspection was a monitoring visit conducted on May 2, 2024, following a self-reported incident received on April 29, 2024, regarding allegations in Resident Care and Related Services.
Findings
The investigation did not support the self-report of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant and reviewed resident and staff records with no substantiated deficiencies found.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of interviews conducted with staff: 1
Number of interviews conducted with residents: 0
Inspection Report
Complaint Investigation
Census: 145
Deficiencies: 1
May 2, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-04-23 regarding allegations related to buildings and grounds at the facility.
Findings
The investigation supported the complaint allegations of non-compliance, resulting in violations being issued. Specifically, the facility failed to ensure required two-hour staff rounds for a resident with inability to use the signaling device during the night of 3/30/2024 and early morning of 3/31/2024.
Complaint Details
Complaint was substantiated based on record review showing missing documentation of two-hour night checks for Resident #1 on 3/30/2024 and early 3/31/2024.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that direct care staff made rounds no less often than every two hours for a resident with inability to use the signaling device during asleep times, as required. |
Report Facts
Number of residents present: 145
Number of resident records reviewed: 3
Number of staff records reviewed: 2
Number of resident interviews conducted: 1
Number of staff interviews conducted: 2
Two-hour rounding frequency: 2
Plan of correction review period: 4
Plan of correction implementation date: 2024.05
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
| Coy Stevenson | Current Inspector | Inspector on-site during the inspection |
Inspection Report
Monitoring
Census: 143
Deficiencies: 1
Apr 4, 2024
Visit Reason
The inspection was a monitoring visit conducted on April 4, 2024, following a self-reported incident received on March 11, 2024, regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with standards or law, resulting in violations issued related to medication administration timing. Specifically, the facility failed to ensure medications were administered within the prescribed time window.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs ordered for specific times. |
Report Facts
Number of residents present: 143
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 3
Medication administration dates missed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
| Health and Wellness Director | Responsible for re-educating staff on medication administration timing |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 3
Nov 8, 2023
Visit Reason
An unannounced complaint inspection was conducted due to a complaint received on 2023-10-25 regarding allegations in resident care and related services.
Findings
The investigation supported the allegation of non-compliance with standards and laws, resulting in violations related to medication administration errors, failure to report major incidents within 24 hours, and failure to admit or retain individuals with prohibitive care needs.
Complaint Details
Complaint related: Yes. The complaint was substantiated as evidence supported non-compliance with standards and laws regarding resident care and medication administration.
Deficiencies (3)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours any major incident negatively affecting resident safety. |
| Facility failed to ensure it did not admit or retain individuals with prohibitive conditions or care needs for two of three records reviewed. |
| Facility failed to ensure medications were administered in accordance with physician's orders for one of three records reviewed, specifically administering incorrect dosage of Lorazepam. |
Report Facts
Residents present at inspection: 52
Resident records reviewed: 3
Staff interviews conducted: 11
Medication error duration: 17
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 5
Oct 30, 2023
Visit Reason
An on-site complaint inspection was conducted due to a complaint received by VDSS Division of Licensing on 2023-09-26 regarding allegations in resident care and related services.
Findings
The investigation did not substantiate the complaint allegations of non-compliance. However, violations unrelated to the complaint were identified during the inspection, including failures in admission criteria, tuberculosis risk assessment, updating personal and social information, and individualized service plan documentation and review.
Complaint Details
Complaint was received on 2023-09-26 regarding allegations in resident care and related services. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure it did not admit or retain individuals with prohibitive conditions or care needs for one of three records reviewed. |
| Facility failed to ensure a risk assessment for tuberculosis was completed annually for one of three records reviewed. |
| Facility failed to ensure personal and social information required by regulations was kept current for one of three records reviewed. |
| Facility failed to ensure the resident's comprehensive individualized service plan included all assessed needs for one of three records reviewed. |
| Facility failed to ensure resident's individualized service plan was reviewed and updated at least once every 12 months and as needed for significant changes for one of three records reviewed. |
Report Facts
Number of residents present: 52
Number of resident records reviewed: 3
Number of staff records reviewed: 0
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 11
Inspection Report
Renewal
Census: 139
Deficiencies: 10
Sep 11, 2023
Visit Reason
An on-site renewal inspection was conducted over multiple days in September 2023 to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations including failure to maintain current individualized service plans, incomplete medication orders, outdated menus, improper hot water temperature, malfunctioning call system, and expired first aid kit items. The facility was determined to be non-compliant with several regulatory standards.
Deficiencies (10)
| Description |
|---|
| Facility failed to ensure it did not admit or retain individuals with prohibitive conditions or care needs. |
| Personal and social information form was not kept current, missing allergy information. |
| Individualized service plans (ISP) did not include all assessed needs for multiple residents. |
| ISPs were not reviewed and updated at least once every 12 months or as needed for significant changes. |
| Menus for meals and snacks were not dated and posted in a conspicuous area. |
| Medications were started, changed, or discontinued without valid physician orders. |
| Physician orders lacked required details including diagnosis or specific indications for medications. |
| Hot water temperature was below the required range of 105-120 degrees Fahrenheit. |
| Staff was unable to determine the origin of the call system signal due to pager issues. |
| First aid kits contained expired items and lacked required supplies. |
Report Facts
Inspection days: 5
Facility census: 139
Hot water temperature: 90
Medication administration times: 4
Expired ointment date: 2023
Expired antiseptic ointment date: 2022
Inspection Report
Complaint Investigation
Census: 128
Deficiencies: 0
Jun 3, 2023
Visit Reason
An unannounced complaint inspection was conducted following an online complaint received on 2023-02-16 regarding allegations in resident care, related services, and increased service charges.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted at the facility.
Complaint Details
The complaint was related to resident care, related services, and increased service charges. The investigation did not substantiate the allegations.
Report Facts
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 9
Inspection Report
Complaint Investigation
Census: 128
Deficiencies: 2
Mar 6, 2023
Visit Reason
An unannounced complaint inspection was conducted on March 6, 2023, following a complaint received on January 25, 2023, regarding allegations in resident care, nutrition, buildings and grounds, and resident care needs.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, violations unrelated to the complaint were identified during the inspection. These violations involved failure to keep resident personal and social data current and failure to ensure comprehensive service plans included all assessed needs.
Complaint Details
Complaint was received by VDSS Division of Licensing on 2023-01-25 regarding allegations in resident care, nutrition, buildings and grounds, and resident care needs. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the resident's personal and social data was kept current, specifically a discrepancy in resident #1's code status documentation. |
| Facility failed to ensure the comprehensive service plan included all assessed needs, specifically resident #2's mobility needs were not fully reflected in the individualized service plan. |
Report Facts
Number of residents present: 128
Number of resident records reviewed: 3
Number of staff records reviewed: 0
Number of resident interviews: 1
Inspection Report
Complaint Investigation
Census: 134
Deficiencies: 7
Oct 24, 2022
Visit Reason
An on-site complaint inspection was conducted due to a complaint received by VDSS Division of Licensing on 10-19-22 regarding allegations in the area of resident care and related services.
Findings
The investigation supported allegations of non-compliance with standards and laws, resulting in multiple violations related to resident care, medication management, documentation, and individualized service plans. Violations included failure to maintain psychotropic treatment plans, incomplete admitting physical exams, outdated social data, missed medication dosages, and unsigned physician orders.
Complaint Details
The complaint investigation was substantiated with violations issued. The complaint was related to resident care and medication management issues, including missed medication dosages and incomplete documentation.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure it did not admit or retain individuals with prohibited conditions or care needs; missing psychotropic treatment plan for resident #4. |
| Admitting physical examination did not include all required information such as height, weight, and blood pressure for resident #3. |
| Social data of residents #1, #3, and #4 was not updated to include all allergy information as required. |
| Individualized service plans for residents #2 and #4 did not include all assessed needs such as physical and occupational therapy services. |
| Resident #1's prescription medication was not ordered and refilled in a timely manner, resulting in missed dosages. |
| Physician's order or prescriber's oral order was not reviewed and signed within 14 days for resident #1's medication administration. |
| Medications were administered outside the facility's standard dosing schedule for residents #1, #2, #3, and #4. |
Report Facts
Residents present: 134
Resident records reviewed: 4
Staff records reviewed: 7
Resident interviews conducted: 2
Staff interviews conducted: 7
Medication administrations outside scheduled time: 6
Medication administrations outside scheduled time: 11
Medication administrations outside scheduled time: 7
Medication administrations outside scheduled time: 12
Medication administrations outside scheduled time: 3
Medication administrations outside scheduled time: 2
Medication administrations outside scheduled time: 3
Medication administrations outside scheduled time: 14
Medication administrations outside scheduled time: 2
Inspection Report
Renewal
Census: 125
Deficiencies: 10
Sep 20, 2022
Visit Reason
An on-site unannounced renewal inspection was conducted by two licensing inspectors from the Peninsula Licensing Office on multiple dates in September and October 2022 to assess compliance with applicable standards and regulations.
Findings
The inspection identified multiple areas of non-compliance including tuberculosis screening for private duty personnel, first aid certification for direct care staff, admission and retention of individuals with prohibitive conditions, fall risk rating updates, maintenance of personal and social information, resident orientation acknowledgments, completion of uniform assessment instruments, individualized service plans, health care service needs documentation, and medication order management.
Deficiencies (10)
| Description |
|---|
| Failed to ensure tuberculosis requirements were applied to private duty personnel. |
| Failed to ensure direct care staff maintained current first aid certification. |
| Failed to ensure admission and retention of individuals with prohibitive conditions or care needs. |
| Failed to update fall risk ratings after resident falls. |
| Failed to keep personal and social information forms current. |
| Failed to obtain acknowledgment of orientation from residents or legal representatives upon admission. |
| Failed to complete uniform assessment instruments with required administrator or designee signatures. |
| Failed to ensure individualized service plans included all assessed needs. |
| Failed to ensure health care service needs of a resident were met and documented. |
| Failed to ensure medication orders were valid and properly documented for discontinuations. |
Report Facts
Inspection dates: 4
Facility census: 125
Records reviewed: 10
Residents with psychotropic medication treatment plan issues: 5
Residents with fall risk rating issues: 2
Residents with personal/social information issues: 2
Residents with orientation acknowledgment issues: 2
Residents with incomplete uniform assessment instruments: 2
Residents with incomplete individualized service plans: 6
Residents with unmet health care service needs: 1
Residents with medication order issues: 2
Inspection Report
Routine
Census: 117
Deficiencies: 6
Mar 7, 2022
Visit Reason
An unannounced IPOC inspection was conducted to review resident and staff records, interview staff, and assess compliance with standards related to personnel, staffing, admission, retention, discharge, and resident care.
Findings
The facility was found deficient in multiple areas including failure to ensure psychotropic treatment plans for residents on psychotropic medications, incomplete individualized service plans (ISPs) that did not reflect assessed needs or updated services, lack of valid physician orders for medication changes, missing diagnosis on medication orders, and failure to document exact oxygen flow rates for residents.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure it did not admit or retain individuals with prohibitive conditions or care needs for three of five residents due to missing psychotropic treatment plans. |
| Facility failed to ensure individualized service plans included all assessed needs for three of five residents. |
| Facility failed to ensure individualized service plans were reviewed and updated at least annually and as needed for three of five residents. |
| Facility failed to ensure no medication was started, changed, or discontinued without a valid physician order. |
| Facility failed to ensure physician or prescriber orders identified diagnosis or specific indications for administering medications. |
| Facility failed to ensure physician or prescriber orders documented exact oxygen flow rate for a resident. |
Report Facts
Census: 117
Inspection Dates: 3
Plan of Correction Completion Date: Apr 30, 2022
Inspection Report
Renewal
Census: 105
Deficiencies: 16
Oct 7, 2021
Visit Reason
A renewal inspection was initiated on September 15, 2021 and concluded on October 7, 2021 to review compliance with applicable standards and regulations for Brookdale Chambrel Williamsburg.
Findings
The inspection identified multiple violations including failure to report major incidents within 24 hours, incomplete staff training records, missing psychotropic treatment plans, incomplete individualized service plans (ISP), medication administration without valid physician orders, improper medication documentation, lack of valid oxygen therapy orders, maintenance and cleanliness issues, inadequate call bell response system, and incomplete first aid kits.
Deficiencies (16)
| Description |
|---|
| Facility failed to report major incidents to the licensing office within 24 hours. |
| One of five sampled staff records did not document at least 18 hours of annual training. |
| Two of five sampled staff records lacked required infection control and mental impairment training hours. |
| One of five sampled staff records lacked documentation of a subsequent tuberculosis evaluation and report. |
| One of five sampled staff records lacked documentation of current certification in first aid. |
| Written work schedule did not indicate person in charge at any given time. |
| Facility admitted or retained individuals with prohibitive conditions or care needs without signed psychotropic treatment plans. |
| Individualized service plans (ISP) did not include all assessed needs or hospice services for sampled residents. |
| Facility failed to meet healthcare service needs for a resident as documented in ISP and progress notes. |
| Medications were started, changed, or discontinued without valid signed physician or prescriber orders. |
| Medications were administered inconsistent with physician or prescriber instructions, including administration after discontinuation. |
| Medication administration records (MAR) lacked documentation of staff initials for administered medications. |
| Oxygen therapy was provided without a valid physician or prescriber order. |
| Interior of the building was not maintained in good repair, clean, and free of rubbish. |
| Staff was unable to receive alerts from the facility's signaling device due to insufficient pagers. |
| First aid kits in buildings were incomplete and contained expired items. |
Report Facts
Inspection dates: 4
Current census: 105
Staff training hours required: 18
Staff training hours documented: 4.25
Infection control training hours required: 2
Mental impairment training hours required: 4
Completion date for corrections: Dec 31, 2021
Percentage of staff records audited monthly: 20
Percentage of resident charts audited monthly: 10
Percentage of staff records audited monthly for TB screening: 25
Percentage of resident apartments visually inspected monthly: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Coy Stevenson | Inspector | Current inspector conducting the inspection |
| Health and Wellness Director | Responsible party for monitoring and corrective actions related to health and wellness | |
| Executive Director | Responsible party for monitoring and corrective actions, including maintenance and staffing | |
| HR Manager | Responsible for auditing employee files and ensuring training compliance | |
| Maintenance Director | Responsible for maintenance and cleanliness of facility |
Inspection Report
Monitoring
Deficiencies: 2
Mar 11, 2021
Visit Reason
A monitoring inspection was initiated due to a self-reported incident regarding allegations in resident care and related areas, conducted remotely due to a state of emergency health pandemic.
Findings
The investigation did not support the self-reported allegation of non-compliance, but violations unrelated to the self-report were identified, including failure to document assessed needs such as skilled nursing and therapy services in the individualized service plan (ISP).
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the individualized service plan (ISP) included all assessed needs for a resident, specifically skilled nursing and fall risk assessed needs were not documented. |
| Facility failed to ensure that the health care service needs of a resident were met, including failure to provide or arrange therapy services as ordered. |
Report Facts
Inspection dates: 4
Completion date for Plan of Correction: May 15, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Coy Stevenson | Inspector | Current inspector conducting the inspection |
| Health and Wellness Director | Responsible for auditing ISPs and implementing Plan of Correction | |
| District Director of Clinical Services | Responsible for re-educating Health and Wellness Director on ISP documentation | |
| Assistant Executive Director | Contacted by telephone to conduct investigation | |
| Staff #1 | Provided documentation and acknowledged deficiencies related to resident care |
Inspection Report
Complaint Investigation
Deficiencies: 3
Nov 2, 2020
Visit Reason
A complaint inspection was initiated on November 2, 2020, regarding allegations in the areas of resident care and related services, administration and administrative services at Brookdale Chambrel Williamsburg.
Findings
The investigation supported the allegations of non-compliance with standards or law, resulting in violations related to failure to comply with resident agreement policies, incomplete individualized service plans (ISP), and missing required signatures on ISPs.
Complaint Details
The complaint was substantiated with violations issued. The complaint related to resident care and administrative services, including failure to notify resident of rate increases and incomplete and unsigned individualized service plans.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure compliance with its resident agreement policies, including failure to provide documentation of notification of resident's rate increase for services. |
| Facility failed to ensure the individualized service plan (ISP) included all assessed needs for resident #1. |
| Facility failed to ensure the individualized service plan (ISP) was signed and dated by the license administrator or designee, the developer, and the resident or legal representative. |
Report Facts
Inspection dates: 4
Audit percentage: 20
Audit percentage: 10
Audit percentage: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Coy Stevenson | Inspector | Named as current inspector conducting the complaint investigation |
| Assistant Executive Director | Contacted by licensing inspector to provide documentation for investigation | |
| Administrator | Contacted by telephone to conduct the investigation | |
| Staff #3 | Interviewed and unable to provide documentation of notification of rate increase | |
| Staff #4 | Interviewed and unable to provide documentation of notification of rate increase | |
| AL Director | Responsible for auditing resident personal service rate agreements and re-education | |
| Health and Wellness Director | Responsible for auditing individualized service plans and re-education |
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