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: March 10, 2021 , March 11, 2021 , March 24, 2021 and March 26, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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 EMERGENCY PREPAREDNESS 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 22VAC40-90 The Criminal History Record Report

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 renewal inspection was initiated on 3-10-21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 87. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 5 resident records 5 staff records, staff schedule, emergency drills, staff schedule, new hires, health oversight and dietary documents for applicable residents submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1030-D
Description:	Based on record review and staff interview, the facility failed to ensure within the first month of employment, staff, other than the administrator and direct care staff, shall complete two hours of training on the nature and needs of residents with cognitive impairments relevant to the population in care. Evidence: 1. Staff #2?s training record submitted on 3-12-21 did not include documentation of the required 2 hours of cognitive training within 1 month of hire. Staff?s date of hire was 11-10-20 (first day of work was 11-11-20). 2.Staff #3?s training record submitted on 3-12-21 documented cognitive training on 9-24-20 but did not include the number of hours. 3. Additional training documentation was requested and received on 3-23-21. Documents submitted for staff #2 and #3 included the facility, memory support training components. The training documented submitted did not include the date of training and did not include documentation of staff #2 and #3?s attendance and number of hours received by staff. 4. Staff #1 and #6 acknowledged, there was no staff signature and no dates of training documenting staff #2 and #3 completed the required 2 hours of cognitive training within 1 month of date of hire.
Plan of Correction:	1. Staff #2 and #3 had completed the required training. Education has been giving to the manager of EMS on ensuring date and signature are checked when education has been completed. 2. To ensure compliance moving forward manager has been given access to the computer training to audit for timely compliance of her staff.
Standard #:	22VAC40-73-1140-B
Description:	Based on record review and staff interview, the facility failed to ensure within four months of the starting date of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairment that meets regulation requirements. Evidence: 1. Staff #5's training document submitted on 3-12-21 did not include the required 10 hours of training in cognitive impairments. The document submitted documented 9 of the required 10 hours. Staff's date of hire was 9-29-20 (first day of work was 10-2-20). 2. Staff #1 and #6 acknowledged on 3-24-21, acknowledged staff #5 did not have documentation of the required number of cognitive training hours.
Plan of Correction:	1. Staff #5 has completed required training. 2. Moving forward the Clinical Coordinator will audit monthly all new staff for required training in the required time frame.
Standard #:	22VAC40-73-70-A
Description:	Based on record review and staff review, the facility failed to ensure it report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. Resident #3's preliminary plan of care dated 2-23-21 documented on 3-1-21 resident had a change in behavior (suicidal ideations). The facility contacted local police and adult protective services for assistance. This incident was not reported to the licensing office. 2. Staff #1 and #6 acknowledged the licensing office was not notified of the incident that occurred on 3-1-21.
Plan of Correction:	1. This was corrected day of exit survey. 2. To ensure this does not happen moving forward all APS calls will be sent to DSS at the same time with the incident report.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure the individualized service plan included all required assessed needs for four of five residents records. Evidence: 1. Resident #1?s uniformed assessment instrument (UAI) dated 2-12-21 documented in the comment section, resident?s hearing aids. The individualized service plan (ISP) dated 2-12-21 did not document resident?s need for hearing aids. Resident?s dressing need assessed as requiring supervision. The ISP did not document supervision need. Resident?s UAI and ISP documented all medications are administered by facility staff. Resident #1?s February 2021 medication administration record (MAR) documented resident self-administers and keep at bedside the following medications: Refresh, Latanoprost and Timolol Maleate eye drops. Resident?s self- administration of medication was not documented on the ISP. 2. Resident #2?s uniformed assessment instrument (UAI) dated 1-8-21 documented dressing need as physical assistance. The individualized service plan (ISP) dated 1-8-21 documented resident needing mechanical help but did not identify type of mechanical device needed. Resident #2?s UAI and ISP documented all medications are administered by facility staff. Resident #1?s February 2021 medication administration record (MAR) documented resident self- administers and keep at bedside the following medications: Betopic, Refresh Optive, Biotin, Polyethylene glycol and Advanced Antacid-Antigas. Resident?s self-administration was not documented on the ISP. 3. Resident #3?s uniformed assessment instrument (UAI) dated 3-1-21 documented resident needed assistance with bathing, toileting, transferring, stairclimbing, and meal preparation. Resident?s psychological consultant and medication administration record (MAR) documented allergy to Sulfa and Alprazolam. Resident #3?s preliminary service plan did not include the aforementioned assessed needs and allergies. 4. Resident #4?s uniformed assessment instrument (UAI) dated 2-15-21 documented resident needed assistance with walking. This assessed need is not documented on the resident?s individualized service plan (ISP) dated 2-16-21. 5. Staff #1 and #6 acknowledged the residents? ISP did not include all assessed needs.
Plan of Correction:	1. ISP/ UAI updated and documentation completed to reflect hearing aids, needed help with dressing and medications that can be self-administered. (4/16/21) 2. ISP / UAI updated and documentation completed to reflect needed help with dressing as physical and medications are to be administered by staff. (4/16/21) 3. ISP / UAI updated and documentation completed to reflect needed assistance with bathing, toileting, transferring, stairclimbing, and meal preparation. (4/01/21)
Standard #:	22VAC40-73-650-B
Description:	Based on record review and staff interview, the facility failed to ensure physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall identify the diagnosis, condition, or specific indications for administering each drug for four of five residents. Evidence: 1. Resident #1?s Medication Profile dated 2-15-21 and signed by the physician did not include diagnosis for Refresh Classic. 2. Resident #2?s January 2021 Physician?s Order Sheet did not include diagnosis for Prevident and Mirtazapine. 3. Resident #4?s January 2021 Physician?s Order Sheet did not include diagnosis for Furosemide, Fluticasone propionate and compression stocking. 4. Resident #5?s January 2021 Physician?s Order Sheet did not include diagnosis for Pantoprazole and Latanoprost. 5. Staff #1 and #6 acknowledged the residents? physician?s orders did not include diagnosis for all medications.
Plan of Correction:	1. Resident #1 Medication Profile updated to list diagnosed for Refresh Classic. 2. Resident #2 Physician's Order Sheet for Prevident and Mirtazapine updated to list diagnosis for each. 3. Resident #4 Physician's Order Sheet for Furosemide, Fluticasone Propionate, and Compression Stockings have been updated to list a diagnosis for each. 4. Resident #5 Physicians Order Sheet for Pantoprazole and Latanoprost have been updated to list a diagnosis for each. 5. To ensure compliance moving forward quarterly audits will be conducted by our Pharmacist from Remedi.
Standard #:	22VAC40-73-680-K
Description:	Based on record review and staff interview, the facility failed to ensure when using PRN medications it followed all requirements of the regulation. Evidence: 1. Resident #4?s February 2021 medication administration record (MAR) and January 2021 Physician Order Sheet documented Acetaminophen Extra Strength maximum dosage 3-4 gms daily. The prescribed (PRN) medication?s dosage is not an exact amount as required by the regulation for PRN medications. 2. Staff #1 and #6 acknowledged the resident?s as needed medication was not an exact amount as required by the regulation.
Plan of Correction:	1. The Physician Order was corrected day of exit survey. 2. To ensure compliance moving forward quarterly audits will be conducted by our Pharmacist from Remedi to check for exact dosage for all medication as required by the DSS regulations.