Inspection Reports for Charter Senior Living of Williamsburg
440 McLaws Cir, Williamsburg, VA 23185, United States, VA
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Inspection Report
Monitoring
Deficiencies: 0
Aug 21, 2025
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 2025-06-10 regarding allegations in the area of Resident Care and Related Service.
Findings
The licensing inspector completed a tour of the physical plant including the building and grounds. The evidence gathered did not support the self-report of non-compliance with standards or law.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 2
Resident interviews conducted: 0
Staff interviews conducted: 2
Inspection Report
Routine
Deficiencies: 0
Aug 21, 2025
Visit Reason
Routine inspection of Charter Senior Living of Williamsburg to review compliance with 22VAC40-73 Resident Care and Related Services regulations.
Findings
The report provides information about the inspection conducted by the Virginia Department of Social Services, with no indication of complaint-related issues or deficiencies noted in the provided text.
Inspection Report
Monitoring
Deficiencies: 0
Aug 21, 2025
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing on 2025-08-01 regarding allegations in the area of Resident Care and Related Service.
Findings
The licensing inspector completed a tour of the physical plant and reviewed resident and staff records. The evidence gathered did not support the self-report of non-compliance with standards or law.
Report Facts
Resident records reviewed: 2
Staff records reviewed: 2
Resident interviews conducted: 0
Staff interviews conducted: 2
Inspection Report
Monitoring
Deficiencies: 0
Aug 21, 2025
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review resident care and related services, including activity calendar, activities, and menu compliance.
Findings
The inspection found no violations with applicable standards or laws. The licensing inspector completed a tour of the physical plant and reviewed resident records and staff interviews without identifying any deficiencies.
Report Facts
Resident records reviewed: 4
Staff records reviewed: 0
Resident interviews conducted: 0
Staff interviews conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Conducted the inspection and is the current inspector for the facility |
Inspection Report
Monitoring
Census: 61
Deficiencies: 2
Jun 16, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care and related services regulations, including additional requirements for adults with serious cognitive impairments.
Findings
The investigation supported the self-report of non-compliance with standards related to resident assessments and supervision. Violations were issued for failure to update Uniform Assessment Instruments after changes in condition and inadequate supervision of residents with wandering behavior.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure Uniform Assessment Instruments (UAIs) were reviewed/completed whenever there is a change in condition. |
| Facility failed to provide supervision of resident schedules, care, and activities including attention to the specialized need of wandering from the premises for one resident in care. |
Report Facts
Number of residents present: 61
Number of resident records reviewed: 5
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 3
Inspection Report
Renewal
Census: 61
Deficiencies: 5
Jun 12, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and regulations.
Findings
The inspection found multiple violations related to individualized service plans (ISPs) and medication administration, including missing dates, signatures, incomplete service plans, and failure to administer medications as prescribed.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure the comprehensive individualized service plan (ISP) included identified needs and date identified. |
| Facility failed to ensure each resident's individualized service plan contained a signature and date of the resident or their legal representative. |
| Facility failed to ensure each resident's individualized service plan was reviewed to include significant changes in the resident's condition. |
| Facility failed to ensure medications were administered in accordance with the physician's or prescriber's instructions. |
| Facility failed to have all required items on the Medication Administration Record (MAR). |
Report Facts
Number of residents present: 61
Number of resident records reviewed: 7
Number of staff records reviewed: 4
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Inspector conducting the renewal inspection |
| Staff # 2 | Named in medication administration deficiency for not administering medication as prescribed |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 2
Feb 25, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-12-27 regarding allegations in the area of Resident Accommodations and Related Provisions.
Findings
The investigation did not substantiate the complaint allegations of non-compliance. However, violations unrelated to the complaint were identified, including failure to have individualized service plans (ISPs) signed and dated by required parties and failure to ensure ISPs were reviewed and updated at least annually.
Complaint Details
Complaint was received on 2024-12-27 regarding Resident Accommodations and Related Provisions. The evidence gathered did not support the allegation(s) of non-compliance.
Deficiencies (2)
| Description |
|---|
| Facility failed to have the ISP signed and dated by the licensee, administrator, or designee and by the resident or legal representative. |
| Facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months and as needed. |
Report Facts
Number of residents present: 61
Number of resident records reviewed: 2
Number of staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 1
Feb 25, 2025
Visit Reason
The inspection was conducted as a complaint investigation following complaints received by VDSS Division of Licensing on 12/27/2024 and 2/18/2025 regarding staffing allegations.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, a violation unrelated to the complaint was identified regarding failure to maintain a current work schedule documenting absences, substitutions, or changes.
Complaint Details
Complaints were received regarding staffing issues. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (1)
| Description |
|---|
| Facility failed to maintain a current work schedule that includes documentation of any absences, substitutions, or other changes to the posted schedule. |
Report Facts
Number of residents present: 61
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 2
Feb 25, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-01-15 regarding allegations related to buildings and grounds at the facility.
Findings
The investigation did not substantiate the complaint allegations; however, violations unrelated to the complaint were identified, including failure to maintain the interior of the building in good repair and failure to document rounds for residents unable to use the call bell system.
Complaint Details
The complaint was related to buildings and grounds. The evidence gathered did not support the allegation(s) of non-compliance with standards or law.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the interior of the building was maintained in good repair, specifically the call bell system was not functioning properly and staff did not respond to call bells in the memory care and assisted living areas. |
| Facility failed to document rounds for residents with an inability to use the signaling device, including time of rounds and staff member who made the rounds. |
Report Facts
Number of residents present: 61
Number of staff interviews: 4
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 0
Feb 25, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on January 27, 2025, regarding allegations related to Resident Accommodations and Related Provisions.
Findings
The investigation did not support the allegations of non-compliance with standards or law. However, violations unrelated to the complaint were identified during the inspection and cited in the violation notice.
Complaint Details
Complaint related to Resident Accommodations and Related Provisions received on 2025-01-27; evidence did not support the allegations but unrelated violations were found.
Report Facts
Number of residents present: 61
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 3
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 4
Feb 25, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-02-18 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the allegations of non-compliance with standards and violations were issued. The facility failed to ensure staff were considerate and respectful of residents' rights and dignity, failed to admit or retain individuals with prohibitive conditions without required documentation, failed to update fall risk assessments after every fall, and failed to ensure accurate counts of controlled substances during staff changes.
Complaint Details
The complaint was substantiated as the evidence gathered supported the allegations of non-compliance with standards related to resident care and related services.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure staff was considerate and respectful of the rights, dignity, and sensitives of persons who are aged, infirmed, or disabled. |
| Facility failed to admit or retain individuals with prohibitive conditions without required documentation. |
| Facility failed to ensure that a fall risk assessment was reviewed and updated after every fall. |
| Facility failed to implement its written plan for medication management, specifically regarding accurate counts of all controlled substances whenever assigned medication staff changes. |
Report Facts
Residents present: 61
Resident records reviewed: 2
Staff records reviewed: 1
Documented falls: 5
Inspection Report
Census: 66
Deficiencies: 1
May 16, 2024
Visit Reason
The inspection was conducted as a self-report following a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance related to failure to provide supervision of resident schedules, care, and activities, including attention to the specialized need of wandering from the premises for one resident. Violations were issued based on staff interviews and documentation review.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide supervision of resident schedules, care, and activities including attention to the specialized need of wandering from the premises for one resident in care. |
Report Facts
Number of residents present: 66
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 3
Incident report date: Apr 22, 2024
Inspection Report
Renewal
Census: 66
Deficiencies: 12
May 14, 2024
Visit Reason
The inspection was conducted as a renewal of the facility's license, including a tour of the physical plant, record reviews, interviews, and observations to assess compliance with applicable standards and laws.
Findings
The inspection found multiple violations related to documentation, staff training, medication management, and facility compliance with health and safety regulations. Violations included missing disclosure statements, incomplete staff training records, expired first aid kit items, medication administration errors, and failure to maintain current health inspection status.
Deficiencies (12)
| Description |
|---|
| Facility failed to provide a disclosure statement to prospective resident and legal representative prior to admission. |
| Direct care staff did not complete required annual training hours. |
| Staff failed to submit timely tuberculosis risk assessments. |
| Direct care staff did not maintain current certification in approved first aid programs. |
| Facility administrator failed to provide written assurance of appropriate license to resident prior to admission. |
| Resident records lacked signed acknowledgements of orientation information. |
| Individualized Service Plans (ISPs) lacked required signatures and dates. |
| Facility failed to maintain current health inspection status with Virginia Department of Health. |
| Facility failed to ensure accurate counts of controlled substances during staff shift changes. |
| Pharmacy reference book used for medication administration was outdated (dated 2019). |
| Medication was administered not in accordance with physician's instructions (resident received medication after breakfast instead of before). |
| First aid kits contained expired items (Triple Antibiotic Ointment expired 5/2021, hand sanitizer expired 9/2023). |
Report Facts
Number of residents present: 66
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of resident interviews conducted: 3
Number of staff interviews conducted: 4
Medication administration observation time: 9.05
Date of expired TB risk assessment: Jul 5, 2022
Date of expired pharmacy reference book: 2019
Date of expired first aid ointment: 202105
Date of expired hand sanitizer: 202309
Date of most recent health inspection: Dec 5, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Named as the current inspector conducting the inspection |
| Staff #2 | Certified nurse aide with missing annual training and acknowledged outdated pharmacy reference book and narcotic count issues | |
| Staff #4 | Certified nurse aide | Missing documentation of 12 hours of annual training |
| Staff #5 | Missing annual TB risk assessment, had non-approved CPR certification, involved in narcotic count issues, medication administration error | |
| Staff #1 | Acknowledged facility's health inspection was not current | |
| Business Office Manager | BOM | Responsible for auditing resident files, staff training, TB assessments, and CPR certifications as part of plan of correction |
| Health and Wellness Director | HWD | Responsible for auditing resident healthcare records and medication management plans |
Inspection Report
Renewal
Census: 48
Deficiencies: 11
May 12, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and laws.
Findings
The inspection found multiple violations including failure to obtain timely criminal history reports for employees, incomplete resident interviews and documentation, missing fall risk assessments, lack of sex offender screenings prior to admission, absence of signed resident agreements, failure to provide orientation to new residents, outdated individualized service plans, incomplete health care oversight records, missing annual resident rights reviews, unsigned verbal physician orders, and incomplete medication administration records.
Deficiencies (11)
| Description |
|---|
| Facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee. |
| Facility failed to ensure a documented interview between the administrator or designee and the resident or legal representative was in the record. |
| Facility failed to ensure that a fall risk assessment was reviewed and updated after every fall. |
| Facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. |
| Facility failed to ensure at or prior to the time of admission, there was a written agreement signed by the resident. |
| Facility failed to ensure upon admission, it would provide an orientation for new residents and their legal representatives. |
| Facility failed to ensure the individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed for significant changes. |
| Facility failed to have a list of specific residents for whom health care oversight was provided. |
| Facility failed to ensure that the annual review of resident rights and responsibilities is filed in the resident's record. |
| Verbal physician orders were obtained without physician's signature on the orders. |
| Facility failed to include all required documentation on the Medication Administration Record (MAR), including missing staff initials for medication administration. |
Report Facts
Number of residents present: 48
Number of resident records reviewed: 11
Number of staff records reviewed: 3
Number of resident interviews conducted: 3
Number of staff interviews conducted: 4
Dates of verbal orders without physician signature: 3
Dates of documented falls without fall risk assessments: 7
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Feb 8, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 11/17/2023 regarding allegations in the areas of Resident Care and Related Services and Buildings and Grounds.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection summary will be posted publicly and a copy of the findings is required to be posted on the facility premises.
Complaint Details
Complaint received on 11/17/2023 regarding Resident Care and Related Services and Buildings and Grounds. The evidence gathered did not support the allegations of non-compliance.
Report Facts
Number of residents present: 42
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: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Renewal
Census: 48
Deficiencies: 7
Jun 21, 2022
Visit Reason
An unannounced renewal inspection was conducted to review compliance with applicable standards and laws, including review of resident and staff files, medication administration records, building and grounds inspection, and other required documentation.
Findings
The inspection found multiple violations including non-compliance with state laws related to business entity status, incomplete background checks for staff, missing verification of professional licenses and certifications, lack of posted CPR certification listings, incomplete health care oversight documentation, missing annual health inspection evidence, and incomplete fire drill records.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure compliance with relevant state laws due to inactive/cancelled LLC status. |
| Facility failed to ensure background checks for staff hired since 11/1/2021 met regulatory requirements. |
| Two of four staff files did not contain verification of current professional license, certification, registration, or completion of required training. |
| Facility failed to have a listing of all staff with current first aid and/or CPR certification posted and readily available. |
| Facility failed to ensure health care oversight for assisted living residents was completed every three months. |
| Facility failed to provide evidence of an annual health inspection by the Virginia Department of Health. |
| Facility failed to ensure fire drills were conducted on each shift in a quarter and not conducted in the same month. |
Report Facts
Residents in care: 48
Staff files reviewed: 4
Resident files reviewed: 8
Staff hired since 11/1/2021: 17
Staff with valid background checks: 3
Staff list provided: 75
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 25, 2022
Visit Reason
The inspection was an unannounced, non-mandated complaint inspection related to staffing and resident care.
Findings
The Licensing Inspector observed the facility memory care unit, staff records, and reviewed additional documentation. There was not enough evidence to support the allegation and the complaint was found not valid.
Complaint Details
The complaint was related to staffing and resident care. The complaint was found not valid due to insufficient evidence.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Rodriguez | Licensing Inspector | Contact person for additional questions or concerns regarding the complaint inspection. |
Inspection Report
Renewal
Deficiencies: 0
Jun 21, 2021
Visit Reason
A renewal inspection was initiated and conducted on 06/21/2021 using alternate remote protocol due to a state of emergency health pandemic declared by the Governor of Virginia.
Findings
The inspection reviewed 4 resident and 4 staff records and additional documentation, determining no violations with applicable standards or law; no violations were issued.
Report Facts
Resident records reviewed: 4
Staff records reviewed: 4
Inspection Report
Monitoring
Census: 52
Deficiencies: 0
Jan 22, 2021
Visit Reason
A focused monitoring inspection was conducted using an alternate remote protocol due to a state of emergency health pandemic declared by the Governor of Virginia.
Findings
The inspection reviewed resident and staff records, staff schedules, and training to ensure compliance with the facility's Intensive Plan of Correction. No violations or deficiencies were found during the inspection.
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