Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Woodhaven Hall At Williamsburg Landing during CMS and state inspections, most recent first.
Two residents with moderate cognitive impairment and known wandering risk eloped multiple times without staff knowledge. One resident, with heart failure, gait abnormality, and a history of falls, removed a wander guard bracelet, exited through the main entrance while the receptionist was on break, and was later found in the parking lot with a facial laceration; the same resident later left the therapy gym unsupervised and again exited through the lobby when no staff were monitoring the entrance. Another resident, with metabolic encephalopathy, schizophrenia, PTSD, and a history of wandering to find family, left the building and was first kept within sight in the parking lot, then on a later occasion eloped again and was found at a distant security gate in another resident’s car, with staff unable to state when she was last seen. Observations showed that wander guard alarms were difficult to hear amid noise and that basement exits and loading dock doors were unlocked and unsupervised, allowing access to the outside despite existing elopement policies and use of wander guard devices.
Dish machine wash and rinse temperatures were not maintained at the proper level to sanitize dishes. Observations showed conflicting temperature readings on the machine gauge, a wall-mounted monitor, and internal thermometers, and the EC verified the water temperatures were not reaching the proper temperature. The EC also reported that prior temperature logs could not be located, and the Sous Chef responsible for recording the readings was not available and not on the schedule.
The facility failed to follow its abuse prevention and injury-of-unknown-origin policies when a resident with dementia and weakness was found on the floor, unwitnessed, complaining of right leg pain and unable to perform active ROM. The resident was sent to the hospital and underwent a right partial hip replacement for a fracture, but the former Administrator did not complete a reportable incident within 24 hours, believing it was related to a fall rather than an injury of unknown origin, contrary to facility policy requiring such injuries to be reported and investigated.
A resident with dementia and weakness was found lying on the floor with right leg pain after an unwitnessed incident and was emergently transferred to the hospital. Facility documentation showed the resident was not interviewed about the event, and leadership later confirmed that the former Administrator did not report this injury of unknown origin to the State Survey Agency as required. Review of facility policy showed that all injuries of unknown source, including those involving possible abuse or serious bodily injury, must be reported immediately, but not later than two hours after the allegation is made.
A resident with dementia and weakness was found on the floor with right leg pain after an unwitnessed incident and was emergently transferred to the hospital. The Day Shift Supervisor interviewed the assigned nurse and two CNAs, who all denied witnessing the fall, but no further interviews or investigative steps were taken to determine how the resident came to be on the floor. Leadership could not provide credible evidence that a thorough investigation was completed, while facility policy required immediate and comprehensive investigation of injuries of unknown source, including expanded staff interviews, written statements, and review of medical records to determine whether abuse occurred and the probable source of the injury.
A resident with dementia and weakness was found lying on the floor, groaning and grimacing in pain with right leg pain and limited ROM, and was sent to the hospital for further evaluation. The SSD reported no one else was nearby and the resident could not explain what happened, but the facility did not provide credible evidence that the event was identified as an injury of unknown source or possible abuse.
Failure to Prevent Multiple Elopements of Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for two residents assessed as elopement risks with moderate cognitive impairment. One resident (R14) had diagnoses including heart failure, acute respiratory failure, abnormality of gait, and a history of falls, and was care planned for wandering with interventions such as use of a wander guard/location monitor and redirection. An elopement assessment identified this resident as having wandering behavior occurring one to three days, at risk for getting to a dangerous place, with worsening behaviors and aimless wandering. Despite this, the resident’s quarterly MDS did not identify wandering behaviors, and the resident was able to remove the wander guard bracelet and leave the building without staff knowledge. In the first elopement event for R14, a utility staff member observed the resident outside in the front parking lot next to his wheelchair, with a bruise and laceration under his right eye. The wander guard bracelet was later found in the resident’s laundry bin, and the resident reported that he had intentionally removed the bracelet because it was uncomfortable and waited until no one was looking so he could go outside. The receptionist, who normally monitored the main entrance, was on break and did not see the resident exit. LPN1 confirmed that the resident had rolled his wheelchair out the door to the front parking lot and that the resident had begun exhibiting increased wandering and exit-seeking behaviors. In the second elopement event for R14, the admission coordinator noticed the resident sitting outside the facility in his wheelchair without staff supervision and redirected him back inside. Investigation showed that a CNA had taken the resident to the therapy gym and informed the PTA, then left after confirming the resident was still in therapy 15 minutes later. When therapy was completed, the PTA placed the resident back in his wheelchair and allowed him to return on his own, not being aware that the resident was a wanderer and not recalling a wander guard bracelet. The resident then turned toward the lobby instead of his unit and exited through the main entrance while the receptionist was again on a scheduled break. The second resident (R59) had diagnoses including metabolic encephalopathy, schizophrenia, anxiety, delusional disorders, PTSD, and abnormality of gait and mobility, with a BIMS score indicating moderate cognitive impairment. The care plan identified potential for falls and wandering, with interventions including monitoring for wandering behavior, redirection, keeping side doors locked, monitoring placement of a wander guard bracelet, and offering 1:1 staff when indicated. A wandering/elopement risk assessment documented a history of wandering to find family or a pet, cognitive impairment, and a recent medication change to decrease behaviors, and led to the decision to add an elopement deterrent device and develop an elopement care plan. For this resident, an earlier elopement incident involved leaving to the parking lot while fixated on finding her daughter, though staff kept her within constant sight and within about 10 feet. A later elopement involved the resident leaving the facility without staff knowledge and being found at a security gate approximately a mile from the entrance, sitting in the passenger seat of an independent living resident’s car. Staff statements indicated they did not see the resident leave and could not identify when she was last observed. It was suspected that she had followed a family or staff member out a side hall door closest to the guard house and main road. LPN2 reported that the resident wore a wander guard bracelet and frequently tried to remove it but did not know where the resident went or where she was found. Additional observations showed that the wander guard alarm for R14’s wheelchair produced an audible alarm that could be hard to hear at the nurses’ station when there was a lot of noise, even though it also displayed on monitors. An elevator near the nurses’ station led to a basement hallway where a second wander bracelet alarm was present, but no staff were in that area during observation. This basement hallway led to an unlocked exit door to the outside and another unlocked door to a loading dock and ramp leading outside. The facility’s elopement policy defined elopement as a resident wandering away without staff knowledge, out of visual sight, and being incapable of finding their way back, and required immediate, coordinated response when a resident was reported missing. The events described showed that both residents were able to exit the facility or reach unsecured areas without staff awareness, despite identified elopement risk and existing policies and interventions. This deficient practice resulted in the identification of Immediate Jeopardy and substandard quality of care at F689, with the Immediate Jeopardy beginning when R59 eloped from the facility and was later found at the security gate in another resident’s car.
Removal Plan
- Provide education to the Director of Nursing, Director of Social Services, the Minimum Data Set Coordinator for the risk of wandering.
- Record assessments in the resident's medical record.
- Identify residents at risk for wandering.
- Maintain wander guards for residents identified to need them.
- Check all external and lobby doors within the health and rehabilitation center to ensure that all doors are secured or have a wander guard system in place.
- Place a staff member to continuously supervise and monitor the lobby area outside of the health and rehab center lobby, elevator, and unsecured areas.
- Maintain supervision of this area until a wander guard is placed to ensure no access to an unsupervised area.
- Provide in-service education to all staff present on the wandering resident policy and wander guard protocol, including identification of residents at risk of wandering, the wander guard system, and the monitoring system of the lobby, secured areas, and the elevator.
- Provide in-service education to all incoming shifts of nurses, certified nursing assistants, and health and rehabilitation center staff on the wander guard system and identified target areas, including newly hired, unscheduled, and contracted staff prior to their next shift in the health and rehabilitation center.
- Assign the Administrator or Director of Nursing to be responsible for implementation of the removal plan.
- Conduct an impromptu Quality Assurance Performance Improvement committee meeting to review the facility's plan of correction and removal of immediate jeopardy, including the Medical Director.
- Inspect the wander guard system for proper function and inspect all exterior doors to ensure substantial compliance is maintained.
- Monitor and review this plan of correction through the Quality Assurance process to ensure ongoing substantial compliance is met, amending the plan of correction as needed.
- Implement the plan of correction.
Dish Machine Temperatures Not Maintained or Documented
Penalty
Summary
The facility failed to ensure the dish machine wash and rinse temperatures were at the proper level to sanitize dishes. During observation, the dishwasher gauge showed the wash cycle at 158 degrees F and the rinse cycle at 150 degrees F, while a second wall-mounted monitor connected to the machine showed the wash cycle at 155 degrees F and the rinse cycle at 188.8 degrees F. The monitor was designed to alert staff when temperatures were out of range, but no alerts had occurred. Because of the discrepancy, the Executive Chef checked the machine with an internal thermometer, which registered 151.4 degrees F, then 158 degrees F on a second rack, and 165 degrees F in the well of the machine. The Executive Chef verified the water temperatures were not reaching the proper temperature. During the same review, the Executive Chef stated that the three-compartment sink would be used in the interim. The next day, representatives from Ecolabs were observed working on the dish machine after the Executive Chef reported that when the machine was turned on earlier that morning, he heard a loud pop and the machine lost all power. The Executive Chef also stated he was unable to locate previous temperature logs for the dish machine and could not validate the logs because he could not find any copies. He identified the Sous Chef as responsible for monitoring and recording dish machine water temperatures for all three meals, but the Sous Chef was not available and was not on the schedule.
Failure to Report and Investigate Unwitnessed Injury With Hip Fracture
Penalty
Summary
The facility failed to implement its policies and procedures related to abuse, neglect, and injuries of unknown origin by not reporting and not investigating an unwitnessed injury that resulted in a hip fracture. One resident, identified as R56, was admitted to the skilled nursing unit with diagnoses including dementia and weakness, and had a BIMS score of 12/15, indicating moderate cognitive impairment. On 01/03/24, an incident/accident report documented that R56 was observed lying on the floor with no witnesses to the event. Upon assessment, the resident complained of right leg pain and was unable to perform active range of motion without pain. Following this unwitnessed event, R56 was transferred to the hospital and underwent a right partial hip replacement due to a fracture. Despite the injury occurring under unwitnessed circumstances, the former Administrator did not complete a facility reportable incident within 24 hours. A written statement from the Executive Vice President/Chief Operating Officer and Chief Clinical Officer indicated that the former Administrator believed the fracture was related to a fall and not an injury of unknown origin. This decision was inconsistent with the facility’s Abuse Prevention Program policy, which requires that injuries of unknown origin be reported, investigated, and managed in accordance with facility procedures and regulatory requirements.
Failure to Timely Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the State Survey Agency (SSA) as required by regulation and its own abuse policy. A resident with dementia and weakness was admitted to the facility and later was found lying on the floor, complaining of right leg pain. The Incident/Accident Report for this event documented that the incident was unwitnessed and that the resident was not interviewed about what had occurred. The resident was emergently transferred to the hospital for medical intervention following this event. A written statement from the Executive Vice President/Chief Operating Officer and Chief Clinical Officer indicated that the former Administrator did not report this incident to the SSA as an injury of unknown origin, despite the circumstances of the resident being found on the floor, in pain, and requiring emergency transfer. Review of the facility’s policy titled “Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property” showed that all injuries of unknown source must be immediately reported to the Administrator, DON, and the applicable State Agency, and that allegations involving abuse or serious bodily injury must be reported immediately, but not later than two hours after the allegation is made. An attempt to interview the former Administrator was unsuccessful.
Failure to Investigate Injury of Unknown Origin After Unwitnessed Fall and Hospital Transfer
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident who required emergent hospital transfer. The resident was admitted with diagnoses including dementia and weakness. An Incident/Accident Report documented that the resident was found lying on the floor, complaining of right leg pain, and that the incident was unwitnessed. The Day Shift Supervisor reported being informed by the Social Services Director that the resident was discovered on the floor and stated she was responsible for follow-up investigation of incident/risk management reports. She interviewed the assigned nurse and two CNAs on the unit, all of whom stated they did not witness the fall. No additional interviews were conducted to determine what led to the resident being found on the floor in pain and then emergently transferred to the hospital. The Executive Vice President/Chief Operating Officer was unable to provide credible evidence to surveyors that a thorough investigation had been completed or to explain the incident. The Chief Clinical Officer stated surveyors were not permitted to review incident/risk management reports, staff statements, or investigative documentation and also did not provide credible evidence that a thorough investigation had been completed. This was inconsistent with the facility’s own policy, which requires the Administrator to immediately begin an investigation of all injuries of unknown source, including interviewing the resident and all witnesses, expanding interviews to prior shifts if there are no direct witnesses, obtaining written statements, and reviewing medical reports and records, and to reach a conclusion regarding whether abuse occurred and the probable source of the injury.
Failure to Identify Unexplained Injury as Possible Abuse
Penalty
Summary
The facility failed to ensure a resident was protected from potential abuse when a resident with dementia and weakness was found lying on the floor with pain in the right leg and limited ability to move the leg without pain. The resident had a BIMS score of 12 out of 15, indicating moderate cognitive impairment. An incident/accident report documented that the resident was observed on the floor, complained of pain, and was unable to perform active range of motion without pain, and the resident was emergently transferred to the hospital for further evaluation. The Social Services Director stated she saw the resident lying on the floor in a lateral position, groaning and grimacing in pain, with no other people in the area. She attempted to ask if he was okay, but he only responded with a groan, and she then located a nurse. The facility did not provide credible evidence that the event was identified as an injury of unknown origin or possible abuse, despite policy language defining injuries of unknown source as unobserved or unexplained injuries that are suspicious based on extent, location, number, or pattern, including injuries requiring hospital transfer.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Williamsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jamestown Health And Rehabilitation | 2 mi | ★★★★★ | 0 | 0 |
| Williamsburg Post Acute & Rehabilitation | 2.3 mi | ★★★★★ | 4 | 0 |
| Riverside Lifelong Health & Rehabilitation Patri | 4.4 mi | ★★★★★ | 0 | 0 |
| Windsormeade Of Williamsburg | 5.8 mi | ★★★★★ | 0 | 0 |
| York Post Acute | 13.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.