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 16, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation

Comments:

An unannounced renewal inspection was conducted on 2-14-22 (ar 07:42 a.m./dep 5:55 p.m.). The facility's census was 93. A tour of the facility was conducted, medication pass observation, activity observed, staff and resident interviews, staff and resident records reviewed; emergency documents reviewed, dietary, pharmacy and healthcare oversight documents were reviewed. The Acknowledgement Form was signed by the administrator. The exit meetings were conducted on 3-14-22; 3-1-22 and 3-9-22. 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. 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. Plan of correction is due with 10 days.(3-26-22). Should you have any questions, give me a call at 757-439-6815 or e-mail, willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1030-D
Description:	Based on record reviewed and staff interviewed, 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 #8?s date of hire documented as 9-28-21. Staff?s record documented 1.0 hour of cognitive training on 11-11-21. 2. Staff #10?s date of hire documented as 12-2-21. Staff?s record did not have documentation of cognitive training. 3. Staff #1 acknowledged non-nursing staff did not have the required two hours of cognitive training within the first month of hire.
Plan of Correction:	1. Staff f#8' only works in IL and never works in AL/MS for dining services. Staff #l0's date of hire documented as 2. 11-2-21 .Staffs record did not have documentation of cognitive training. 3. To ensure all staff receive required cognitive training in the required time frame, the staff member will be preassigned to our CDP class and Relias training to have all required hours of training. 4. Moving forward the Residents Services Coordinator /administrative assistant will audit monthly all new staff for required training in the required time frame.
Standard #:	22VAC40-73-260-A
Description:	Based on record review and staff interviewed, the facility failed to ensure each direct care staff who does not have current certification in first aid as specified in subdivision 1 of subsection 260-A of the regulation shall receive certification in first aid within 60 days of employment. Evidence: 1. Staff #10?s date of hire documented as 11-1-21. Staff?s record did not have documentation of first aid certification. 2. Staff #1 acknowledged staff did not have training within 60 days, stated staff was signed up for the class in March 2022.
Plan of Correction:	I. Staff #10's date of hire documented as11-1-21.Staff's record did not have documentation of first aid certification. 2. Staff member has been registered for class. 3. To ensure this does not occur again upon hire ensure a class is arranged immediately prior to 60 day expiration. 4. The administrative assistance will make sure when in processing a new employee this is arranged.
Standard #:	22VAC40-73-450-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure preliminary plan was signed and dated by the licensee, administrator, or designee and the resident or his legal representative. Evidence: 1. Resident #3?s preliminary ISP in the record was not signed and dated. The resident?s initial uniformed assessment instrument (UAI) was dated and signed by facility representative on 7-28-21 and date of admission was dated 7-28-21. 2. Staff #3 acknowledged the aforementioned resident?s preliminary ISP was not signed and dated.
Plan of Correction:	1. Resident #3's preliminary ISP in the record was not signed and dated. The resident's initial uniformed assessment instrument (UAI) was dated and signed by facility representative on 7-28-21 and date of admission was dated 7-28-21. Updated with signature. 2. To ensure this does not occur again will we will have the resident or family signs upon presentation of ISP. 3. Manager of Memory Support, Resident Services Social Worker, Resident Services Coordinator, and Manager of Assisted Living will audit each other's ISP/UAI to ensure compliance by discussing prior to ISP meetings.
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) contained all assessed needs for six of ten residents. Evidence: 1. Resident #4?s uniformed assessment instrument (UAI) dated 1-4-22 documented transferring need as independent. The individualized service plan (ISP) dated 2-4-22 documented resident as mechanical help needed, use of walker and arms of chair for transferring need. Walking and stairclimbing need assessed as mechanical help. The ISP documented need as mechanical help/ supervision. 2. Resident #6?s UAI dated 12-14-21 documented medication to be administered by ?RN, LPN, RMA?. The resident?s February 2022 medication administration record (MAR) documented Tylenol and Loperamide, and ?may leave at bedside/ self-administers?. This assessed need was not documented on the ISP. 3. Resident #7?s UAI dated 12-20-21 documented stairclimbing need as mechanical help/physical assistance and mobility as mechanical help/supervision. The ISP dated 12-21-21 documented need as mechanical help only. Cognition need on UAI documented disoriented some spheres some time (Time and Place). Resident?s physical examination dated 11-20-20 documented the following allergies: Prednisone, Paxil, Cephalosporins, onions, peas and cats. These assessed needs were not documented on the ISP. 4. Resident #8?s UAI dated 9-30-21 documented bathing need as mechanical help/supervision. The ISP dated 9-15-21 documented resident needed mechanical and physical assistance. The UAI documented medication administered by, ?RN, LPN, CMT?. The resident?s February 2022 medication administration record (MAR) documented, ?may self- administer and keep at beside Vicks Baby Rub?. This assessed need was not documented on the ISP. 5. Resident #9?s UAI dated 10-18-21, bathing need assessed as mechanical help. The ISP dated 10-19-21 documented mechanical help and supervision. Resident?s physical dated 9-3-20 documented resident allergic to ?Contrast dye?. This assessed need was not documented on the ISP. 6. Resident #10?s UAI dated 4-14-21 documented bathing need assessed as mechanical help/physical assistance. The ISP dated 2-4-22 documented mechanical help/supervision. Walking need assessed as mechanical help. The ISP documented mechanical help/physical assistance. Stairclimbing need assessed as mechanical help/supervision. The ISP documented mechanical help/ physical assistance. The resident wears hearing aids, this information is not documented on the ISP. 7. Staff #1 acknowledged the aforementioned resident?s ISPs did not include all assessed needs.
Plan of Correction:	1, Resident #4 ISP/UAI updated and documentation completed to reflect transferring need as mechanical. 2. Resident #6 ISP/ UAI updated and documentation completed to reflect medication administration and that Tylenol, Loperamide may be left at bedside. 3. Resident #7 ISP/UAI updated and documentation completed to reflect needed stairclimbing as physical assistance and mobility as mechanical help/supervision. Cognition updated as disoriented some time (Time, Place). Allergies added: Paxil, Cephalosporin's, onions, peas, and cats. 4. Resident #8 ISP/ UAI updated and documentation completed to reflect bathing as needed mechanical and physical assistance and will reflect medication administration of Vicks Baby Rub can to be left at bedside. 5. Resident #9 ISP / UAI updated and documentation completed to reflect bathing needed documented resident needed mechanical and added that Contrast Dye resident is allergic to. 6. Resident #10 ISP/UAI updated and documentation completed to reflect bathing documented resident as needed mechanical and physical assistance, walking as mechanical/physical assistance, and stairclirnbing mechanical help. Wearing hearing aids was added. 7. To ensure this will not happen when status changes occur to the resident's needs, ISP will be updated at the same time as UAI, these will be discussed during ISP to ensure all items are inclusive. 8. Manager of Memory Support , Resident Services Social Worker, Resident Services Coordinator, and Manager of Assisted Living will audit each other's ISP/UAl to ensure compliance by discussing prior to ISP meetings and validate understanding of medication pass.
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was reviewed and updated as needed as the condition of the resident changes for two of ten residents. Evidence: 1. Resident #1?s record documented resident received physical therapy services (PT) 1-7-22 through 1-20-22. The ISP dated 9-21-21 did not document this service. 2. Resident #3?s record documented resident receive mental health services, referral in record dated 11-18-21. This information was not documented on the ISP dated 2-15-22. 3. Staff #1 acknowledged the resident?s ISP was not updated as needed as the condition of the aforementioned residents? changed.
Plan of Correction:	1. Resident #1 ISP record documented resident received physical therapy services (PT) 1-7-22 through 1-20-22. The ISP dated 9-21-has been updated to reflect the documentation of this service. 2. Residents #3 's record documented resident receive mental health services, referral in record dated 11-18-21.This information has been documented on the ISP dated 2-15-22. 3. To ensure this will not happen when status changes occur to the resident's needs, ISP will be updated at the same time as UAl, these will be discussed during ISP to ensure all items are inclusive. 4. Manager of Memory Support , Resident Services Social Worker, Resident Services Coordinator,and Manager of Assisted Living will audit each other's ISP/UAl to ensure compliance by discussing prior to ISP meetings.
Standard #:	22VAC40-73-580-D
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure when a resident has been assessed on the UAI as dependent in eating/feeding, the individualized service plan (ISP) shall indicate an approximate amount of time needed for meals to ensure needs are met. Evidence: 1. Resident #2?s uniformed assessment instrument (UAI) dated 6-9-21 documented resident is spoon-fed. The ISP dated 6-15-21 did not include the approximate amount of time needed for meals. 2. Staff #3, on 2-14-22, acknowledged the aforementioned resident?s ISP did not include the approximate eating time.
Plan of Correction:	1. Resident #2 's uniformed assessment instrument (UAI) dated 6-9-21 documented resident is spoon-fed. The ISP dated 6-15-21 did not include the approximate amount of time needed for meals. 2. Plan to ensure this will not happen when status changes occur to resident's needs, ISP will be updated at the time as UAJ, these will be discussed during ISP to ensure all items are inclusive. 3. Manager of Memory Support Resident Services Social Worker, Resident Se1vices Coordinator, and Manager of Assisted Living will audit each other's ISP/UAI to ensure compliance by discussing prior to ISP meetings.
Standard #:	22VAC40-73-680-B
Description:	Based on observation and staff interviewed, the facility failed to ensure medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. Evidence: 1. On 2-14-22 during the medication pass observation with staff #3 and #5, it was observed that staff #5 had prepared medications for residents in advance of administering to the resident. On the medication cart there medications pre-poured in advance for fourteen (14) residents on the second floor. 2. Staff #3 and #5 acknowledged the medications were observed on the medication cart and were prepared in advance of administering to 14 residents.
Plan of Correction:	1. It was observed that staff#5 had prepared medications for residents in advance of administering to the resident and on the medication cart there medications pre- poured in advance for fourteen (14) residents on the second floor. 2. Agency Nurse was removed from facility due to her practicing outside of the medication administration protocol. 3.To ensure this does not occur again all new staff receive medication management education before passing medications and will validate verbally to off going nurse.
Standard #:	22VAC40-73-700-2
Description:	Based on record reviewed, observation and staff interviewed, the facility failed to ensure it post ?No Smoking-Oxygen in Use? sign and enforce the smoking prohibition in any room of a building where oxygen is in use. Evidence: 1. Resident #2?s record documented resident?s physical dated 12-29-21 documented resident?s need for Oxygen. Resident?s February 2022 medication administration record (MAR) and ISP dated 2-4-22 documented resident needs Oxygen continuously. 2. During a tour of the building on 2-14-22 and signaling device check in resident?s room, the inspector noticed the ?No Smoking- Oxygen in Use? sign was not in the resident?s room and not on the resident?s door. 3. On 2-14-22, staff #2 acknowledged the No Smoking sign was not posted.
Plan of Correction:	1. During a tour of the building on 2-14-22 and signaling device check in resident's room, the inspector noticed the ''No Smoking - Oxygen in Use" sign was not in the resident's room and 2/14/22 not on the resident's door. Corrected day of inspection. 2. Plan to ensure this will not happen again when oxygen is ordered an oxygen sign will be placed at that time. 3. There will be an order placed in the residents chart when oxygen is ordered to ensure sign is placed on residents room.