Deficiency Records for Williamsburg Post Acute and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Williamsburg Post Acute and Rehabilitation. 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 approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-08 | 2024-01-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-08 | 2024-01-18 | N |
| Have an externally vented heating system. | Fire Safety | 2024-01-08 | 2024-01-18 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2024-01-08 | 2024-01-18 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-10-20 | 2023-12-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-20 | 2023-12-05 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-10-20 | 2023-12-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-20 | 2023-12-05 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-10-20 | 2023-12-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-20 | 2023-12-05 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-10-20 | 2023-12-05 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-10-20 | 2023-12-05 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-20 | 2023-12-05 | N |
| Respond appropriately to all alleged violations. | Health | 2023-10-20 | 2023-12-05 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-10-20 | 2023-12-05 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-10-20 | 2023-12-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-20 | 2023-12-05 | 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 | 2023-10-20 | 2023-12-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-20 | 2023-12-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-20 | 2023-12-05 | N |
| Provide appropriate foot care. | Health | 2023-10-20 | 2023-12-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-20 | 2023-12-05 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-10-20 | 2023-12-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-20 | 2023-12-05 | 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 | 2023-10-20 | 2023-12-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-10-20 | 2023-12-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-20 | 2023-12-05 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-10-20 | 2023-12-05 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-10-20 | 2023-12-05 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-10-20 | 2023-12-05 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-10-20 | 2023-12-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-14 | 2023-07-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-13 | 2023-05-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-13 | 2023-05-16 | 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 | 2023-04-13 | 2023-05-16 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-04-13 | 2023-05-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-13 | 2023-05-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-04-13 | 2023-05-16 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-04-13 | 2023-05-16 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-04-13 | 2023-05-16 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-04-18 | 2023-05-16 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-04-18 | 2023-05-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-04 | 2023-01-02 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-11-04 | 2023-01-02 | 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 | 2022-11-04 | 2023-01-02 | 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 | 2022-11-04 | 2023-01-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-04 | 2023-01-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-04 | 2023-01-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-04 | 2023-01-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-04 | 2023-01-02 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-04 | 2023-01-02 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-11-04 | 2023-01-02 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-11-04 | 2023-01-02 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-11-04 | 2023-01-02 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-11-04 | 2023-01-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-04 | 2023-01-02 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-11-04 | 2023-01-02 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-11-04 | 2023-01-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-30 | 2022-12-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-30 | 2022-12-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-05 | 2022-05-09 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-05 | 2022-05-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-05 | 2022-05-09 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-05-05 | 2022-05-09 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-05 | 2022-05-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-30 | 2022-05-09 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-30 | 2022-05-09 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-08-11 | 2021-09-22 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-11 | 2021-09-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-11 | 2021-09-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-11 | 2021-09-22 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-08-11 | 2021-09-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-11 | 2021-09-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-11 | 2021-09-22 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2021-04-30 | 2021-05-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-30 | 2021-05-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-30 | 2021-05-20 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-04-30 | 2021-05-20 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-04-30 | 2021-05-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-30 | 2021-05-20 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-04-09 | 2021-05-20 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-04-09 | 2021-05-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-09 | 2021-05-20 | Y |
