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: Dec. 14, 2020 , Dec. 15, 2020 , Jan. 13, 2021 and Jan. 28, 2021

Complaint Related: No

Areas Reviewed:

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. The monitoring inspection was initiated on 12-14-20. A self-reported incident was received by the department regarding allegation in the areas of resident care and related services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-450-F
Description:	Based on record review and staff interview, the facility failed to ensure individualized service plan shall be reviewed and updated as needed as the condition of the resident changes. Evidence: 1. Resident #1?s individualized service plan (ISP) dated 4-24-20 did not document resident?s change in condition and weight loss documented in resident?s Clinical Notes dated 8-11-20. 2. Staff #5 and #6 acknowledged resident?s ISP was not updated to reflect resident?s change in condition.
Plan of Correction:	1. ISP updated and documentation complete to reflect weight loss and plans to help resident gain weight and maintain moving forward. (1/31/21)
Standard #:	22VAC40-73-460-D
Description:	Based on record review and staff interview, the facility failed to ensure it provided supervision of resident schedules, and activities, including attention to specialized needs such as wandering from the premises for a resident. Evidence: 1. Facility incident report on 12-4-20 documented resident #1 exited the front door of the memory support building behind a delivery man. Two private duty aides who are familiar with resident saw him through a window and went out through the door to retrieve him. After they escorted resident back in, they alerted WL staff. 2. Interview with C-1 confirmed resident #1 was outside the memory support building on the courtyard side of the building. C-1 observed resident #1 on the sidewalk from the window of another resident?s room. C-1 went outside and brought resident#1 back into the building. C-1 stated, did not know how long resident #1 was outside, but hand was cold. (The accuweather.com temperature for the Williamsburg area for December 4, 2020 was high of 61 degree/ low of 46 degrees). C-1 stated, ?the facility was busy and staff was not aware resident was outside the building". 3. Interview with facility staff members #1, #2 and #4 confirmed staff were not aware that resident had exited the building and was outside. Staff members also confirmed it was a busy afternoon, the delivery driver was there to make a delivery, family members were present and it was also near dinnertime. 4. All staff members interviewed acknowledged resident was outside the special care building on 12-4-20.
Plan of Correction:	1. Education provided to those involved and instruction provided again that when accessing the door you must wait until door closes and locks before moving from door. (12/4/2020) 2. Employee that violated procedure for allowing entrance into Memory Support and did not monitor door to close and lock before moving on was terminated (12/8/2020)
Standard #:	22VAC40-73-580-F
Description:	Based on record review and staff interview, the facility failed to ensure interventions were implemented as soon as a nutritional problem was suspected for a resident. Evidence: 1. Resident #1?s Clinical Notes dated 8-11-20 at 15:07 documented ?Change in Condition? weight loss by resident. The notes documented, resident #1?s physician office and facility staff discussed resident?s ?weight loss?. The notes also documented, ?the recommendation was Ensure. The nutritionist and dining staff made aware of resident?s weight loss?. Resident?s Ensure supplement was not documented on resident #1?s September 2020, October 2020 and November 2020 medication administration record (MAR). 2. Resident?s physical examination dated 4-17-20 documented resident?s weight at 155 pounds. Resident?s admission date documented as 4-24-20. The notes dated 11-25-20, documented the nutritionist review of resident?s weight as, ?weight is trending downward?. In addition the note documented resident?s ideal body weight (IBW) was 184 pounds. The note also documented the following weights for resident since admission: Nov 2020- 140.2 pound; October 2020- 144.2 pounds; August- 144.6 pounds and May 147.8 pounds. 3. Staff #5 acknowledged resident weight loss during this period.
Plan of Correction:	1. Diet changed to reflect dietician's recommendation to ensure correct diet is being offered. (1/21/21) 2. Supplements added to offer resident other alternatives when he is not interested in the meal that is being offered. Weight is to be taken monthly to ensure his increase continues and is sustained. (1/31/21) 3. Psych consulted for paranoia towards his food and perceptions of his food is poisoned. Weight is to be taken monthly to see that his increase continues and is sustained. (1/31/21)