Woodhaven Hall at Williamsburg Landing

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to provide supervision and ensure resident safety for two of six Residents (Resident (R)14 and R59) reviewed for elopement. As a result, R14 and R59, who had been assessed as an elopement and fall risk with moderate cognitive impairment, exited the facility without staff knowledge. R14 was found sitting in the parking of the facility next to his wheelchair with a bruised laceration under his right eye and eloped a second time. R59 also eloped from the facility two times, with one of the times being found a mile from the entrance of the facility. This had the potential to result in serious injury, harm, impairment, or death. This deficient practice resulted in the identification of Immediate Jeopardy and substandard quality of care. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure the dish machine wash and rinse temperature was at the proper temperature to sanitize the dishes. This had the potential to affect 44 of 44 skilled nursing residents who consumed food from the kitchen.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure residents were protected from potential abuse for one of one resident (Resident (R) 56) reviewed for an injury of unknown origin. R56 was discovered on the floor with signs and symptoms of pain and was emergently transferred to the hospital for further evaluation. There were no witnesses to the incident, and the resident did not explain the reason he was on the floor and in pain. The facility's failure to identify the incident as an injury of unknown origin caused the resident to be a possible victim of abuse.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to implement its policies and procedures related to abuse, neglect, and injuries of unknown origin. The facility failed to report an injury of unknown injury and failed to complete an investigation related to an injury for one Resident (Resident (R) 56) of one resident reviewed for potential abuse and neglect out of a total sample of 14 residents. R56 was found on the floor with no witnesses and sustained a right hip fracture requiring surgical repair. This had the potential for abuse as the injury was not reported or investigated. (Cross Reference F609 and F610)

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure that an injury of unknown origin was reported to the State Survey Agency (SSA) immediately but not later than two hours for one of one resident (Resident (R) 56) reviewed for injuries of unknown origin out of 14 sampled residents. This failure placed the resident and other residents who are discovered to have an injury of unknown origin at risk of sustaining injuries that could have been caused by abuse. (Cross Reference: (F600, F607, and F610)

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure an injury of unknown origin that required an emergent hospital transfer was investigated to determine if the incident was a result of abuse for one of one resident (Resident (R) 56) reviewed for injuries of unknown origin out of 14 sampled residents. The facility's failure to investigate R56's injury of unknown origin to determine if the injury was sustained because of abuse placed the resident at risk of being a victim of potential abuse. (Cross Reference: F600, F607 and F609).

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to conduct COVID-19 testing in accordance with CDC (Centers for Disease Control) and CMS (Centers for Medicare & Medicaid Services) guidance/requirements for 4 out of 6 staff members, staff members #4, #5, #6, and #8, the facility staff failed to maintain documentation of COVID-19 testing occurrences and results for all facility staff, and the facility staff failed to conduct COVID-19 testing for 4 out of 4 newly admitted residents, residents #46, #57, #110, and #209.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to implement their policy and procedure to ensure that all facility staff were fully vaccinated for COVID-19. The facility staff failed to document the COVID-19 vaccination status for 56 contracted nursing agency staff members who provided direct resident care during the months of June, July, and August 2022.

Inspectors wroteBased on interview, clinical record review, and facility documentation the facility staff failed to promote and facilitate resident self-determination through support of Resident choices, for 1 Resident (# 110) in a survey sample of 47 Residents.

Inspectors wroteBased on clinical record review and staff interview, the facility staff failed to provide an ABN (Advanced Beneficiary Notice) for one Resident (Resident #54) in a sample size of 3 Residents.

Inspectors wroteBased on observations, staff interview, clinical record review, and facility documentation review, the facility staff failed to review and revise the care plan for 2 Residents (Resident #43, Resident #113) in a sample size of 47 Residents. 1) For Resident #43, the facility staff failed to revise the care plan for 10 out of 10 falls that have occurred in March and April 2022. 2) For Resident #113, the facility staff failed to review and revise care plan upon discovery of arterial and pressure wounds.

Inspectors wroteBased on observation, interview, clinical record review, facility documentation and during the course of a complaint investigation the facility staff failed to provide care that meets professional standards of care for 2 Residents (# 113 and # 43) in a survey sample of 47 Residents.

Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to ensure freedom from accident hazards by providing adequate supervision to prevent accidents, for 1 Resident (# 14) in a survey sample of 47 Residents.

Inspectors wroteBased on observation, interview, facility documentation and clinical record review the facility staff failed to appropriately label and store insulin in one of the two medication carts.

Inspectors wroteBased on interview, clinical record review, facility documentation and in the course of an investigation, the facility staff failed to provide and accurate clinical record for 1 Resident (# 114) in a survey sample of 47 Residents.

Inspectors wrote2. For Resident #158 (on Transmission-Based Precautions), the facility staff failed to post signage to indicate what personal protective equipment (PPE) should be worn prior to entering the room. On 08/16/2022 at approximately 1:05 P.M., this surveyor observed Transmission-Based Precautions (TBP) supplies outside Resident #158's room but there was no signage to indicate what PPE should be worn prior to entering the room. At approximately 1:10 P.M., Certified Nursing Assistant E (CNA E) was observed at nurse's station. When asked about what PPE should be worn prior to entering Resident #158's room, CNA E indicated that all PPE, except eye protection, should be worn upon entering Resident #158's room. On 08/16/2022 at 2:30 P.M., CNA D was interviewed. [...]

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide pneumococcal immunizations for 3 residents in a survey sample of 5 residents reviewed for pneumococcal vaccination. The facility staff failed to provide pneumococcal immunizations for Residents #8, #14, and #53.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to provide COVID-19 immunization for 2 staff members, staff #7 and #8, in a survey sample of 5 staff members reviewed for COVID-19 vaccination. The facility staff failed to provide COVID-19 booster vaccines for staff members #7 and #8.

Inspectors wrote12. On 5/29/19 at 12:40 PM while observing lunch in second floor dining room, EMPLOYEE M was observed plating and serving meals. At 12:41 PM while wearing gloves Employee M scratched her face then platted food for cart. After plating the food she took off her gloves and did not wash hands. She then was approached by a staff member who wanted ice cream for a Resident's tray. Employee M scooped the ice cream without washing hands or donning gloves. At 12:42 PM she then put on gloves still without washing her hands, touched the top and sides of food cart while moving it out of her way. She then plated more food and then placed it on the cart then walked away from food prep area came back a minute later and with same gloves on began chopping carrots and chicken for a patient with a chopped diet. At 12:45 PM she removed the gloves and again did not wash her hands. [...]

Inspectors wroteBased on observation, staff interview, clinical record review, facility documentation review, the facility staff failed to maintain infection prevention practices to prevent the potential for transmission of infections involving two residents (Resident #279, 278) in a sample size of 29 residents.

Inspectors wroteBased on staff interview, facility documentation review, and clinical record review, the facility staff failed to assess that the Resident was safe to self-administer medications for two Residents, (Resident #326, Resident #325) in a survey sample of 29 Residents.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to implement their abuse policy.

Inspectors wroteBased on clinical record review, staff interview, and facility documentation review, the facility staff failed to notify the ombudsman of transfer to hospital for one resident (Resident #275) in a sample size of 29 residents.

Inspectors wroteBased on staff interview, facility documentation and clinical record review the facility staff failed to ensure the Resident had a Level I PASARR screening for 2 Residents (#278 and #5) of 29 residents prior to admission to the facility

Inspectors wroteBased on observation, Resident interview, clinical record review, staff interview, and facility document review, the facility staff failed to provide a base line, or comprehensive care plan for urinary suprapubic catheter for one Resident (Resident #22) in a survey sample of 29 residents.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to review and revise the careplan after a change in treatment, for one Resident (Resident # 327) in a survey sample of 29 residents.

Inspectors wroteBased on observation, Resident interview, clinical record review, staff interview, and facility document review, the facility staff failed to provide urinary suprapubic catheter care and serives to one Resident (Resident #22) in a survey sample of 29 residents.

Inspectors wroteBased on staff interview, and facility documentation review, the facility failed to provide annual nursing staff training based on their annual reviews.

Inspectors wroteBased on observation, staff interview, facility documentation and clinical record review the facility staff failed to provide Dementia Services to attain highest practicable well-being for 1 Resident (#5) in a survey sample of 29 Residents.

Inspectors wroteBased on observation, staff interview, facility documentation and clinical record review the facility staff failed to ensure routine medications were available for administration for 2 Residents (#18 and #278) in a survey sample of 29 Residents.

Inspectors wroteBased on observation and staff interview, the facility staff failed to employ staff with appropriate competencies to carry out the functions of food and nutrition services.

Inspectors wroteBased on staff interview, facility documentation review, and clinical record review the facility staff failed to transmit resident assessment information for 5 Residents (Resident #2, Resident #3, Resident #4, Resident #5, and Resident #8) in a survey sample of 29 Residents.