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. 18, 2021 , Feb. 24, 2021 and Feb. 18, 2021

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

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. A monitoring inspection was initiated on 2-18-21. A self-reported incident was received by the department on 2-17-21 regarding allegations in the area 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 #:	22VAC40-73-440-H
Description:	Based on record review and staff interview, the facility failed to ensure the resident was reassessed using the Uniformed Assessment Instrument (UAI) due to a significant change in the resident?s condition. Evidence: 1.Resident #1?s Uniformed Assessment Instrument (UAI) dated 5-18-20 was not updated to reflect the resident?s changes in condition. Resident?s UAI documented resident?s behavior as appropriate and no need for psychological evaluation. The record documented psychological evaluation request was completed on 7-22-20 and behavioral health services received. Behavioral services dated 10-22-20, 10-29-20 and 12-6-20 document resident receiving services for a variety of concerns, including wandering and inappropriate behavior. The individualized service plan dated 10-20-20 also documented the need for behavioral health services. 2. Staff #1 acknowledged, the resident?s UAI was not reassessed following a significant change in the resident?s condition.
Plan of Correction:	1. Uniformed Assessment Instrument has been corrected to update the residents' changes in condition. 2. Moving forward UAI will be updated with significant changes to reflect the needs of resident.
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 reported on 2-16-21, resident #1 exited the facility memory support unit unnoticed. Resident, ?entered the Assisted Living Facility across the street at 1:15pm where staff was able to secure him and call for assistance.? This incident is the resident?s third elopement from the facility in less than six months since admission on 4-24-20. 2.Interview with staff #6, the resident was observed outside the entrance door to the Assisted Living. Staff stated, ?resident was not wearing a mask, looked confused, shirt was half in/half out of pants and not wearing a coat?. Resident was given a mask and staff stated calling the Memory Support Unit informing of a resident being in the Assisted Living building. 3.Interview with facility staff members #2, #3, #4 and #5 confirmed staff were not aware that resident had exited the Memory Support building. Staff members also confirmed it was a busy time of the day. The residents were completing the lunch hour, the nurse was with the podiatrist and the two direct care staff were taking care of a resident who became ill. The activity coordinator was working with someone on the computer (Infocus Program). Memory Support Staff #2, #3 and #5 acknowledged during interview, having knowledge of the resident?s previous elopements from the building. Staff stated not being aware that there were movers in the facility who were using the staff entrance door to enter and exit the building during the time of resident #1?s elopement. 4.All staff members interviewed acknowledged resident was outside the Memory Support Unit on 2-16-21.
Plan of Correction:	1. Education provided to those involved and instruction provided again that when allowing access to Memory Support the door must close before you move from opening. (2/16/21) 2. All staff reminded that whenever visitors are in the building you must monitor them. (2/16/21) 3. Employee that violated procedure for allowing entrance into Memory Support and did not follow badge protocol was terminated. (2/18/21) 4. All four doors now are required badge access in and out. Only staff can allow entrance to Memory Support (4/7/21) 5. All access codes have been disabled.
Standard #:	22VAC40-73-650-B
Description:	Based on record review and staff interview, the facility failed to ensure the physician or other prescriber?s orders, both written and oral, for administration of all prescription and over-the-counter medications shall include the diagnosis, condition, or specific indications for administering each drug. Evidence: 1.Resident #1?s February 2021 medication administration record (MAR) did not include the diagnosis, or specific indications for administering the Triamcinolone topical cream. A review of the December 2020 Physician Order Sheet provided documented ?diagnosis exempt?. 2.Staff #1 acknowledged, the MAR and physician?s order did not include the required diagnosis.
Plan of Correction:	1. The option for Diagnoses exempt has been removed from the electronic medical record medication order entry. 2. Quarterly audits will be completed by our Pharmacy consults (Remedi) this Will ensure all medication compliance is met for DSS regulations.