Woodhaven Hall At Williamsburg Landing
Woodhaven Hall at Williamsburg Landing in WILLIAMSBURG, VA — inspection on February 27, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of a printed Incident/Accident Report, dated 01/03/24, provided by the Administrator, revealed R56 was observed lying on the floor.
Upon assessment resident complained of pain in right leg.
Unable to perform active range of motion without pain.
First responder [Social Services Director (SSD)] approached nurse to inform resident observed lying on the floor. R56 was transferred to the hospital following the incident where he was found on the floor (unwitnessed) and subsequently underwent a right partial hip replacement due to a fracture. On 02/25/26, the Administrator provided a written statement composed by the Executive [NAME] President/Chief Operating Officer (ExVPCOO) and Chief Clinical Officer (CCO) of Independent Living Health Services indicating that the former Administrator did not complete a facility reportable incident within 24 hours because he believed the fracture was related to a fall and not an injury of unknown origin.An attempt was made to contact the former Administrator and was unsuccessful.
Review of the facility's policy titled Abuse Prevention Program revealed that injuries of unknown origin must be reported, investigated, and managed in accordance with facility procedures and regulatory requirements.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
495184 02/27/2026
Woodhaven Hall at Williamsburg Landing 5500 Williamsburg Landing Dr Williamsburg, VA 23185
authorities.
record review, interview, and facility policy review, the facility failed to ensure that an injury of
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: (F-F600, F-F607, and F-F610)Findings include: Review of R56's printed Face Sheet, provided by the Administrator, revealed R56 was admitted to the facility on [DATE] with diagnoses including dementia and weakness.
Record review of a printed Incident/Accident Report, dated 01/03/24, provided by the Administrator, revealed R56 was observed lying on the floor and complained of right leg pain.
The report indicated the incident was unwitnessed and R56 was not interviewed about the incident. On 02/25/26, the Administrator provided a written statement composed by the Executive [NAME] President/Chief Operating Officer (ExVPCOO) and Chief Clinical Officer (CCO) of Independent Living Health Services indicating that the former Administrator did not report to the SSA the incident where R56 was discovered on the floor, in pain, and emergently transferred to the hospital for medical intervention as an injury of unknown origin. An attempt was made to interview the former Administrator and was unsuccessful.
Review of the facility's policy titled, Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property, approved 12/2025 revealed, .It is the facility's policy to investigate all.injuries of unknown source.Facility staff must immediately report all such allegations to the Administrator.
The Administrator will immediately.notify the applicable local and state agencies in accordance with the procedures in this policy.6.
Initial Reports. a.
Timing.
All allegations of Abuse.Injuries of Unknown Source.must be reported immediately to the Administrator, Director of Nursing (DON) and to the applicable State Agency. If the event that caused the allegation involves an allegation of Abuse or serious bodily injury, it should be reported.immediately, but not later than 2 hours after the allegation is made.
495184 02/27/2026
Woodhaven Hall at Williamsburg Landing 5500 Williamsburg Landing Dr Williamsburg, VA 23185
During an interview on 02/24/26 at 6:33 PM, the Day Shift Supervisor (DSS) stated she was informed by the Social Services Director (SSD) that a resident (R56) was discovered on the floor.
The DSS also stated that she was responsible for doing a follow-up investigation of any incident/risk management reports that were completed.
The DSS further stated she interviewed the assigned nurse and two certified nurse assistants (CNAs) assigned to the unit on the day of the incident, and all reported they did not witness the fall.
However continued interview revealed no other interviews were conducted and it was not determined what led to the resident being discovered lying on the floor in pain and then emergently transferred to the hospital. On 02/25/26, Executive [NAME] President/Chief Operating Officer (ExVPCOO) provided no credible evidence to the inspectors that a thorough investigation had been completed when R56 was discovered on the floor and could not explain the incident.
During an interview on 02/25/26 at 6:00 PM, the Chief Clinical Officer (CCO) stated that surveyors were not permitted to review incident/risk management reports, staff statements, or investigative documentation.
The CCO provided no credible evidence to the inspectors that a thorough investigation had been completed after R56 was discovered lying on the floor, in pain, and then emergently transferred to the hospital for medical intervention. An attempt was made to contact the former Administrator and was unsuccessful.
Review of the facility's policy titled, Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property, approved 12/2025 revealed, .The facility will not tolerate abuse.It is the facility's policy to investigate all allegations, suspicions, and incidents of abuse.and injuries of unknown source.The Administrator will immediately begin an investigation.DEFINITIONS: Abuse- includes.injuries of unknown source.Injury of Uknown Source-An injury is classified as an 'Injury of Unknown Source' when both the following are met: a.
The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and b.
The injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular time, or the incidence of injuries over time.7.
Investigate.
Once the Administrator and DON [Director of Nursing] are notified, an investigation of the allegation or suspicion will be conducted. a.The investigation must be completed within five working days from the alleged occurrence. b.The person investigating the incident should generally take the following actions: I.
Interview the resident., and all witnesses.II. If there are no direct witnesses, then the interviews may be expanded.For Injuries of Uknown Source, the investigation will generally involve talking with both the shift on duty when the injury was discovered and prior shifts as well. III. obtain written statements from the resident, if possible, the accused, and each witness. IV.
Obtain all medical reports and statements from physicians and/or hospitals, if applicable.
Review the resident's records.8.
Reach a Conclusion.
After completion of the investigation, all of the evidence should be analyzed, and the Administrator (or his/her designee) will make a determination regarding whether the allegation or suspicion is substantiated, and, for Injuries of Unknown Source, a determination regarding the probable source of the injury.
495184 02/27/2026
Woodhaven Hall at Williamsburg Landing 5500 Williamsburg Landing Dr Williamsburg, VA 23185
The survey team validated the implementation of the removal plan through observations, staff interviews, and record reviews.
The IJ was removed on 02/27/26 at 5:15 PM, and the scope and severity was lowered to an G actual harm.