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 23, 2022 , April 11, 2022 , April 30, 2022 and May 2, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

22VAC40-73-440- uniformed assessment signatures for facility employee

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 3-6-2022 regarding allegations in the areas of resident care and related services. One resident record was reviewed and interviews with facility staff, agency staff and collateral interviews were conducted. An on-site visit was conducted on 3-23-22 and 4-30-22. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s individualized service plan (ISP) included the assessed needs for a resident. Evidence: 1. During a complaint inspection for a resident residing on the facility?s safe, secure unit, regarding wound care services, resident #1?s uniformed assessment instrument (UAI) dated 3-15-22 and individualized service plan (ISP) dated 3-15-22 noted the following: (a) dressing need assessed as human help/physical assistance. The ISP noted resident requires supervision with dressing. (b) Toileting need assessed as yes, the UAI did not document the level of functioning. The ISP documented resident requires mechanical assistance, use of grab bars. (c) Transferring need assessed as human help/physical assistance. The ISP documented mechanical assistance with transfers; staff to ensure resident has chair arms available when transferring. (d) Bowel and bladder need assessed as yes. The UAI did not document the level of functioning. The ISP documented resident is incontinent of bladder weekly or more and wear depends and pads with staff assisting as needed. (e) Walking needs assessed as no and functional level assessed as human help/physical assistance. The ISP did not include walking. Resident was observed with a walker on 3-23-22. (f) Wheeling need assessed as no and functional level documented as human help/supervision. The ISP did not include wheeling. (g) Stairclimbing need assessed as human help/supervision. The ISP documented mechanical assist with stair climbing and supervision; staff will ensure that handrails are in place and supervise as needed. (h) Behavior pattern was documented as appropriate. The resident?s ?March 2022 Non-PRN Treatment Notes? noted behavior monitoring by shift starting 12-08-2021. The March 2022 document also included daily documentation by staff regarding behavior for the day, evening and night shift. Staff #1 acknowledged on 5-18-22 the resident?s UAI and ISP did not reflect resident?s assessed needs.
Plan of Correction:	1.(A) The UAI and ISP corrected on 5/23/22 to match and state the entire picture of resident?s needs. Dressing requires physical assistance. (B) The UAI and ISP corrected on 5/23/22 to match and state the entire picture of resident?s needs. Toileting requires physical and mechanical assistance. c) The UAI and ISP corrected on5/23/22 to match and state the entire picture of resident?s needs. Transferring requires Physical/ mechanical assistance. (D) The UAI and ISP corrected on 5/23/2 to match and state the entire picture of resident?s needs. Bowel and bladder requires physical assistance. (E) The UAI and ISP corrected on 5/23/22 to match and state the entire picture of resident?s needs. Walking requires physical/mechanical help. (f) The UAI and ISP corrected on 5/23/22 match and state the entire picture of resident's needs. Wheeling requires no help. (g) The UAI and ISP corrected on 5/23/22 to match and state the entire picture of resident's needs. Stairclimbing requires physical/ mechanical help. (h) The UAI and ISP corrected on 5/23/22 to match and state the entire picture of resident's Needs. Behavior pattern assessed with wondering with redirections. To ensure ISP/UAI show entire Picture of resident care the SW will audit after completed.