Williamsburg Post Acute & Rehabilitation

On 11/13/25 a review of the pharmacy policy regarding unavailable medications read as follows:

• Notify the attending physician (or on-call physician when applicable) of the situation and explain the

circumstances, expected availability, and alternative therapy if available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or directions.

• Obtain new order and cancel / discontinue the order for the non-available medication.
• Notify the pharmacy of the replacement order.

On 11/13/25 during the end of day meeting, the Administrator, Interim Director of Nursing, New Director of Nursing and Regional Director of Clinical Services were made aware of concerns, and no further information was provided.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Williamsburg Post Acute & Rehabilitation

1235 S Mount Vernon Avenue Williamsburg, VA 23185

SUMMARY STATEMENT OF DEFICIENCIES

• Notify the attending physician (or on-call physician when applicable) of the situation and explain the

circumstances, expected availability, and alternative therapy (ies) if available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or directions.

• Obtain new order and cancel / discontinue the order for the non-available medication.
• Notify the pharmacy of the replacement order.

On 11/13/25 during the end of day meeting, the Administrator, Interim Director of Nursing, New Director of Nursing and Regional Director of Clinical Services were made aware of concerns, and no further information was provided

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Williamsburg Post Acute & Rehabilitation

1235 S Mount Vernon Avenue Williamsburg, VA 23185

SUMMARY STATEMENT OF DEFICIENCIES

Based on interviews and facility document review, the facility failed to designate an individual as the infection preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program (IPCP) for the facility.Findings include:The facility administration failed to designate an individual who had completed specialized training in infection prevention and control practices to oversee the facility's Infection Prevention and Control Program. On 11/12/25 a review was conducted on the facility's infection control binder which revealed the Infection Control Tracking Log (surveillance log) dated 7/1/25 through 7/31/25 was incomplete for 5 residents for onset date, site, infection related diagnosis, culture/labs/diagnostic test results, organism, antibiotics, isolation, whether infection was healthcare associated infection or not and date resolved.

The Infection Control binder was further reviewed and revealed that from May to present numerous months were incomplete for infection control tracking logs, McGeer's criteria, mapping and monthly reports. On 11/12/25 an interview was conducted with the Interim Director of Nursing (Employee #3) and the Regional Director of Clinical Services (Employee #4) on incomplete infection control program reports and tracking and they replied that they had had several people overseeing the facility's infection control program since the former Assistant Director of Nursing had left in April and they had not filled that position.

Copies of the Infection Control training certification for the staff overseeing the program since April were requested and the Regional Director of Clinical Services provided a copy of CDC's Nursing Home Infection Preventionist Training Course Certification for 8/20/25 through 10/20/25 for the former Interim Director of Nursing and another certificate for the current Interim Director of Nursing 10/20/25 to present but no evidence that an individual was designated as the Infection Preventionist who had completed specialized training/certification in infection prevention and control for the time period of 5/1/25 through 8/20/25 A review of the facility's Infection Control Policies provided by the Administrator was completed:The policy entitled: Infection Control Program revealed:Policy: Specific Procedures/Guidance 1. h.

Monitoring and timely reporting of infection control data as required by federal and state regulations or guidance.2.

The Infection Control program will be overseen by the Infection Preventionist in collaboration with Medical Director/Designee, Pharmacy Representative, Director of Nursing, Administrator and other staff were assigned.The policy entitled: Infection Preventionist Policy revealed:Policy: Specific Procedures/Guidance3.

The Infection Preventionist will collect, analyze and provide infection and antibiotic usage data and trends to nursing staff and health care practitioners; consult on infection risk assessment and prevention control strategies; provide education and training; and the implementation of evidence-based infection prevention and control practices.The policy entitled: Infection Preventionist - Job Description revealed:Qualified Candidate: Educational and Certification Requirements Certification in Infection Control and Epidemiology (i.e.: CIC copyrighted preferred) or, attainment prior to employmentOn 11/13/25 during the end of day meeting, the Administrator, Interim Director of Nursing, New Director of Nursing, Regional Director of Clinical Services and Regional Director of Operations were made aware of concerns, and no further information was provided.

Facility ID: