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: Jan. 24, 2023 , Jan. 26, 2023 , Jan. 30, 2023 and Feb. 2, 2023

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 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal An unannounced renewal inspection was conducted on-site on 1-24-23 (Ar 09:15 a.m./dep 18:00 p.m); 1-26-23 (Ar 08:00 a.m./dep 17:45 p.m) 1-30-23 (ar 09:55 a.m./dep 18:10 p.m.). The census on day 1 was 93. A tour of the main facility was conducted, medication pass observation in the main building on day 1 and day 2 in the safe, secure unit. Resident and staff interviews were conducted, breakfast meal observed in the safe, secure unit, emergency preparedness items check, including 48 hour food and water supplies. A preliminary exit meeting was conducted each day with the administrator and other team members. Additional documents were requested to be sent via email on 1-26-23 and 1-30-23. On 2-3-23 a virtual preliminary meeting was conducted to review a staff record requested on 1-30-23. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-1140-E
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure within four months of employment direct care staff, shall complete 10 hours of training on the nature and needs of residents with cognitive impairments relevant to the population in care. Evidence: 1. On 1-30-23, Staff #?7s date of hire was documented as 3-7-22. Staff?s record (Relias) documented cognitive training started 7-20-22, 2. Staff #9?s date of hire was documented as 2-15-22. Training document (Relias) received from staff #11 documented training started on 6-29-22. Training document received from staff #4 following third preliminary exit on 2-3-23 documented 8 hours of cognitive training, certificate dated 4-15-22.
Plan of Correction:	1. All items that were noted out of compliance will be completed by the Managers of those departments to reflect updated requirements. 2. Facility will audit 5 direct care staff files weekly x2 months to ensure all required training has been completed. 3. The Manager of Assisted Living and Memory Support will ensure the employees responsible for maintaining employee records are compliant.
Standard #:	22VAC40-73-70-A
Description:	Based on record reviewed, policy reviewed and staff interviewed, the facility failed to ensure it reported the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare for five of ten residents? record reviewed. Evidence: 1. On 1-24-23 and 1-26-23, the sampled residents? clinical notes were requested and provided. Resident #4?s ?Clinical Notes Report (CNR) documented on 1-1-23 resident observed sitting on shower floor; 1-2-23 documented ?resident is S/P fall from two nights ago?. On 1-3-23 ?resident?c/o pain of the lower back and coccyx area since fall.? On 1-4-23, ??still c/o pain of 9 PSR, facial grimacing noted? X-ray of L spine for fall with worsening pain?resident now c/o L. hip pain when ambulating?. On 1-5-23, resident out to local hospital for pain from previous fall. On 1-12-23 resident was seen by medical provider as ?follow up from post fall from last week. Noted swelling and redness of the lower R leg/calf area. Resident c/o numbness of the R foot and coldness noted. New order to send to ER for venous doppler study to R/O DVT and evaluation/treat. Resident returned -no new order or assistive device. 2. Resident #5?s CNR documented on 11-23-22, was sent to a local hospital due to shortness of breath?resident returned and ?has a order for 3Lof continuous oxygen?. 3. Resident #7?s CNR documented on 7-1-22, ?resident assessed by practitioner and was sent out to ER for swelling to BLE?. On 8-19-22, resident reported to practitioner ?having intermittent chest pain on ?left side of chest that is radiating to the right?. Orders to send resident out via 911 following practitioner?s assessment. On 12-21-22, resident c/o lower left abdominal to almost groin pain?resident sent to local hospital. Resident returned, ?CT scan show a hernia?small stones inside kidney?no infection?pain medication ordered?. On 1-9-23, ?sent to ER for groin and left leg pain?returned, ordered Keflex for 7 days for cellulitis, Lasix for 10 days for edema and PRN Norco?for pain?. On 1-14-23, ?resident sent to ER for left groin and leg pain?. 4. Resident #9?s CNR documented on 7-26-22...found on floor...blood observed dripping from the left side of residents head?911 call?. 5. Resident #10?s CNR documented on 10-17-22, ??in dining room?resident fell down. Addendum note, ??resident did in fact strike head?according to CNA who witnessed the fall. Small, raised area noted to the left side of forehead?Assessed by practitioner, POA transported to the hospital?. 6. Facility Policy, ?Incident Reports and Reporting Guidelines (IRRG)? Section II.D.8 - Reporting Guidelines noted: The following are considered to be a major incidents and must be reports as required by the Department of Social Services ?incidents that require the assistance of an outside agency such as police, fire, rescue or emergency community service board contact. II.C of the IRRG noted: ?an email report to the Regional Licensing Office will be made within one-working day of any major incident that has negatively affected or that threatens the life, health, safety or welfare of any resident?. The policy reference noted ?VA Code 22VAC40-73-70 on incident reports?. 7. On 1-30-23 during review of documents with staff #3 and #4, staff acknowledged the incident reports were not submitted to licensing.
Plan of Correction:	1. Facility will notify VDSS of any major incidents that threaten the life, health, safety, or welfare of residents within 24hours. 2. A Final Report will be sent within 7 days as required. 3. Manager of Assisted Living/ Memory Support will be responsible for reporting this to VDSS. Completion date: Ongoing
Standard #:	22VAC40-73-220-A
Description:	Based on observation, staff interviewed and collateral interview, the facility failed to ensue when private duty personnel provide direct care or companion services the identified needs shall be reflected on the resident?s individualized service plan. Evidence: 1. On 1-24-23, a private duty personnel was observed in resident #1 and #2?s apartment. The inspector interviewed the private duty personnel, who stated providing services for both residents. According to staff #4, the private sitter is assigned to resident #2. Resident #2?s ISP dated 8-25-22 did not document private sitter services. 2. Resident #8 receives private sitter services. Facility ?resident private duty sitter/caregiver for? documented resident receives ?help w/dressing and showering, accompany to meals and activities? form is dated 10-5-20 by staff #1. These services are not documented on resident?s ISP dated 8-16-22. ISP documented mobility services provided by private caregiver. 3. Staff #4 acknowledged the private sitter needs and duties were not address on resident #2 and #8?s ISP.
Plan of Correction:	1. Resident #1, #2, and #8 ISP?s have been updated to reflect required documentation of services provided by Private Duty Aides 2. Facility will review four ISP?s weekly x2 months, for residents with private duty personnel, to ensure that identified needs are reflected on the service plan. 3.This will be completed by Manger of Assisted Living and Memory Support
Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit/retrain individuals with a prohibitive condition or care needs in accordance with 63.2-1805 D of the Code of Virginia for three of ten records reviewed. Evidence: 1. On 1-24-23, record review with staff #3 and #4, resident #1?s January 2023 physician order sheet (POS) and medication administration record (MAR) documented resident prescribed Escitalopram. The record did not have documentation of a signed and dated psychotropic treatment plan for this medication. 2. Resident #?2?s January 2023 POS and MAR documented resident prescribed Escitalopram. The record did not have documentation of a signed and dated psychotropic treatment plan for this medication. 3. Resident #6?s January 2023 POS documented resident prescribed Alprazolam. The record did not have documentation of a signed and dated psychotropic treatment plan for this medication. 4. Staff #4 acknowledged the residents? record did not have a signed and dated psychotropic treatment plan for the prescribed psychotropic medication.
Plan of Correction:	1. Resident?s #1, #2, and #6 Treatment Plans have been updated and signed by the Residents Primary Care Physician. 2. Facility will audit 5 charts weekly x2 months to ensure that the residents receiving psychotropic medications have appropriate treatment plans in place. 3. This will be completed by Manager of Assisted Living and Memory Support
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 nine of ten residents. Evidence: 1. Resident #1?s uniformed assessment instrument (UAI) dated 8-12-22 documented transferring need as mechanical help (mh). The individualized service plan (ISP) dated 2-25-22 documented resident as mechanical help needed, chair arms, grab bars and walker...care staff will cue resident. Walking assessed as mh; ISP documented use of cane and/or walker and facility will remind resident to use device. Facility initial assessment (8-12-21) documented resident?s use of hearing aid, this need not documented on ISP dated 2-25-22. 2. Resident #2?s January 2023 POS and January 2023 MAR documented resident allergic to Azor, Pentazocine, ACE Inhibitors, Atenolol, Donepezil, Hydralazine, Lisinopril, Nifedipine, Olmesartan and Potassium Gluconate. These allergies were not documented on the resident?s ISP dated 8-25-22. UAI dated 7-21-22 documented resident disoriented some spheres all the time to time. The ISP did not document what services were to be provided for the assessed need. 3. Resident #3?s hearing aids were not documented on the ISP dated 12-14-22. Resident observed with hearing aids during medication pass with staff #2. Staff stated resident had hearing aids in both ears. 4. Resident #4?s August 2022 POS signed 12-17-22 documented resident?s hearing loss and presence of cardiac pacemaker. These assessed needs were not documented on resident?s ISP dated 6-15-22. 5. Resident #5?s UAI dated 9-22-22 documented bathing need as mechanical help/supervision; the ISP dated 9-22-22 documented use of grab bench and shower bars. Stairclimbing need assessed as mh/supervision, the ISP documented, ?resident need equipment or device and requires verbal and/or prompting?? The January 2023 POS documented resident receives mental health services. Staff #4 confirmed resident receives services. This was not documented on the ISP. The UAI and ISP document medication is administered by facility staff. The resident?s January 2023 MAR documented resident self-administers Ensure three times a day. This self-administration is not on the ISP. 6. Resident #6 admitting physical examination dated 3-16-22 documented occupational., physical therapy and vestibular therapy services. These assessed services were not documented on the ISP. The resident?s medical assessment documented the resident?s pacemaker interrogated. This pacemaker was not documented on the ISP. The UAI dated 3-23-22 documented wheeling as mh/physical assistance (pa); the ISP documented the resident has a motorized wheelchair. Stairclimbing need assessed as mh/pa; the ISP documented, ?resident usually needs equipment or device and requires physical assistance from others?? 7. Resident #7?s, UAI dated 3-21-22 and 1-23-2023 documented medication administered by facility staff. Prior to 1-23-22, staff administered only resident?s eyedrops all other medications administered by resident. This self-administration was not documented on resident?s ISP dated 3-22-22. According to staff #3 and #4, the facility now administers resident?s medication, the ISP documented resident receives ?assistance with eye drops from RMA, LPN, RN.? 8. Resident #8?s, UAI dated 8-10-22 documented resident wanders weekly or more and is aggressive weekly or more. These needs are not documented on the ISP dated 8-16-22. Resident assessed as disoriented some spheres, some time to time and place. The ISP did not document what services to be provided. Mobility assessed as mh/s, the ISP documented ?resident usually requires assistance of another person? (private aide) who supports or steadies the individual to go outside?.
Plan of Correction:	1. Resident?s #1, #2, #3, #4, #5, #6, #7, #8, and #9 ISP?s noted in violation have been corrected and updated to reflect resident?s needs as identified on their current UAI. 2. Facility will randomly audit 5 charts x2 months weekly. This will ensure the coordination of needs. 3. The interdisciplinary team led by the Manager of Assisted Living will oversee this process.
Standard #:	22VAC40-73-580-B
Description:	Based on observation and staff interviewed, the facility did not have a written agreement signed and dated by both the resident and the licensee or administrator and filed in record for residents who routinely have meals in their rooms and have a documented mental health concern. Evidence: 1. On 1-24-23, record reviewed with staff #3 and #4, resident #1?s individualized service plan (ISP) dated 8-25-22 documented resident eats breakfast, lunch and dinner meals in the resident?s apartment with spouse. ?Culinary team will stock continental breakfast and pack meals to go. Direct care staff will ensure meals are delivered?. 2. According to staff #4, resident #2 consumes meals in room with spouse. The inspector observed the private sitter preparing breakfast for resident #2 on 1-24-23 during a medication pass observation with staff #5. 3. Staff #3 and #4 acknowledged the residents? record did not include an agreement for eating meals in room and residents did not have a qualified mental health assessment based on resident?s diagnosis and prescribed medication.
Plan of Correction:	1. Resident?s #1, #2 records have been corrected to reflect a written agreement, signed and dated by the Administrator and resident which meets criteria for dining in their apartment. 2. Facility will assess all current residents who eat meals in their apartments. A meeting will be held to ensure a written agreement is implemented or appropriate plan agreed to for a medical variance by both the resident and Administrator or designee, signed and scanned into their chart. 3. The Manager of Assisted Living and Manager or Memory Support will audit and ensure compliance.
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the facility first aid kit included all required items. Evidence: 1. On 1-24-23, the first aid kit on the first floor checked with staff #2, the hand sanitizer was dated 8-2022 and there were no extra batteries for the flashlight. 2. On 1-26-23, the first aid kit in the safe, secure unit did not have extra batteries for the flashlight and there was no hand sanitizer in the kit. 3. Staff #2 and #6 acknowledged the first aid kit reviewed did not included all required items.
Plan of Correction:	1. The First Aid Kit has been updated and all out of date items have been removed and replaced accordingly. 2. Assisted Living and Memory Support will audit and ensure compliance.