VIRGINIA DEPARTMENT OF SOCIAL SERVICES

WoodHaven At Williamsburg Landing
5500 Williamsburg Landing
Williamsburg, VA 23185
(757) 253-0303

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: Feb. 27, 2020 and March 5, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

An unannounced monitoring inspection was conducted on 2-27-20 (ar 11:00 am/dep 5:30 pm) and 3-5-20 (ar 12:05 pm/dep 1:00 pm) in response to a resident's elopement from the facility on 2-9-20. Staff and collateral interviews were conducted and resident record was reviewed.. An exit was conducted on 2-27-20 with the administrator. The acknowledgement form was signed by the administrator. The exit was conducted with the assisted living manager on 3-5-20 and the acknowledgement form was signed. Please complete the 'Plan of Correction' and 'Date to be Corrected' for each violation cited on the violation notice and return it to me within 10 calendar days from today (3-19-20). You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible.

Violations:

Standard #:	22VAC40-73-1100-A
Description:	Based on record review and staff interview, the facility failed to ensure prior to placing a resident with a serious cognitive impairment diagnosis of dementia in a safe, secure environment, the facility obtained the written approval of one of the individuals listed in accordance with the order of priority specified. Evidence: 1. On 2-27-20 during a review of resident #1's record with staff #1, #2 and #4, the record did not contain documentation of the approval of someone from the order of priority specified in the regulation. 2. The uniformed assessment instrument (uai) and staff indicated resident was relocated to safe, secure unit on 2-24-20. 3. The inspector was escorted to the safe, secure building on 2-27-20 and saw resident #1 on the unit.. 3. Staff #1 and #2 acknowledged resident #1's record did not contain written approval from someone from the order of priority before being placed on the unit.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure description of identified need and date identified based upon staff observation and discussion was included on a resident individualized service plan (ISP). Evidence: 1. On 2-27-20 during a review of resident #1's record with staff #1 and #2, it was revealed resident #1's need for sitter/companion services. 2. A review of resident #1's individualized service plan (ISP) dated and signed 12-10-18, with and end date of 12-10-19 with staff #2, did not include need for sitter/companion services. 3. Further review of resident #1's ISP signed and dated 12-17-19, with an end date of 12-17-20 with staff #2, did not include resident's need for sitter/companion services. 4. According to interview with staff #1 and #2, resident #1's need for sitter/companion services began in the assisted living building, prior to movement to the safe, secure unit building. 5. Documentation provided to the inspector on 2-27-20 noted, on 12/17/19, discussion was conducted with resident #1's representative indicated resident's " private duty hired for evening hours(7:30 pm - 7:3am). Another note indicated "wife has hired additional care, we will be monitoring resident to determine timing for transition to memory support". 6. Resident's current ISP indicated resident attends Adult Day Program multiple times per week, however, not specific days or times is noted. 7. On 2-27-20, resident was observed in the safe, secure building. The current ISP signed and dated 12-17-19 did not include this change in location. 8. Staff #1 and #2 acknowledged resident #1's ISP was not updated to reflect resident caregiving need, days of attendance at the Adult Day Support and relocation to the facility's safe, secure building.
Plan of Correction:	Not available online. Contact Inspector for more information.