Deficiency Records for Consulate Healthcare of Williamsburg
Updated as of March 01, 2024
A list of the most recent deficiencies for Consulate Healthcare of Williamsburg. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-19 | 2022-06-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-12 | 2022-06-28 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-06-22 | 2022-06-28 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-06-22 | 2022-06-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-22 | 2022-06-28 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-05-12 | 2022-06-28 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-05-12 | 2022-06-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-12 | 2022-06-15 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-05-12 | 2022-06-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-05-12 | 2022-06-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-05-12 | 2022-06-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-05-12 | 2022-06-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-12 | 2022-06-15 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-05-12 | 2022-06-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-12 | 2022-06-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-05-12 | 2022-06-15 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-05-12 | 2022-06-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-12 | 2022-06-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-12 | 2022-06-15 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-05-12 | 2022-06-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-31 | 2022-04-22 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2022-03-31 | 2022-04-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-31 | 2022-04-22 | Y |
| Help the resident make transportation arrangements to and from radiology services. | Health | 2022-03-31 | 2022-04-22 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-03-31 | 2022-04-22 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-31 | 2022-04-22 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-31 | 2022-04-22 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-04-14 | 2021-05-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-03-05 | 2020-04-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-03-05 | 2020-04-14 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-03-05 | 2020-04-14 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-03-05 | 2020-04-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-03-05 | 2020-04-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-03-05 | 2020-04-14 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2020-03-05 | 2020-04-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-03-05 | 2020-04-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-05 | 2020-04-14 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-09-27 | 2018-11-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-27 | 2018-11-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-09-27 | 2018-11-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-09-27 | 2018-11-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-09-27 | 2018-11-01 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-08-30 | 2018-10-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-30 | 2018-10-31 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-08-30 | 2018-10-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-08-30 | 2018-10-02 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-08-30 | 2018-10-02 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-08-30 | 2018-10-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-30 | 2018-10-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-30 | 2018-10-02 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-11-02 | Not Fixed | N |
