VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Dominion Village of Williamsburg
4132 Longhill Road
Williamsburg, VA 23188
(757) 258-3444

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: Dec. 16, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 BUILDING AND GROUNDS

Comments:

A Licensing Inspector with the Division of Licensing conducted an announced, non-mandated initial inspection on 12/16/2019 from approximately 9:35am to approximately 10:45am.The facility had 39 residents in care. During the Licensing Inspection the facility Administrator was available and on-site during the complete inspection. The Licensing Inspector observed the facility physical plant, tested water temperatures and the facility call bell system, observed the facility memory care to include facility secured doors, windows and exits, observed resident apartments in memory care and assisted living, reviewed all required items posted and observed residents engaged during activities on the facility memory care unit as well as the facility assisted living unit. Areas of non-compliance are found within this violation notice. Please complete the "plan or correction" and "date to be corrected" for each violation cited on the violation notice and return to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring preventative. Please contact the facility Licensing Inspector Kimberly Rodriguez at 804-396-5696 or by email at kimberly.rodriguez@dss.virginia.gov for additional questions or concerns.

Violations:

Standard #:	22VAC40-73-860-G
Description:	Based on a test of the facility water temperature, the facility failed to ensure hot water taps available to residents shall be maintained within a range of 105 F to 120F. Evidence: On 12/16/2019 with the facility Administrator, while conducting a test of the facility common area restroom water it was found that the restroom sink water on taps read 123F.
Plan of Correction:	Steps to correct the noncompliance with the standards: 22VAC40-73-(8)-860-G A plumber was called in on 12/16/2019 and found that a circulating pump was not functioning properly. A new circulating pump was ordered and installed on 12/19/2019. The water heater temperature has been adjusted to below 120F and above 105F. Measures/systematic changes put in place to ensure that the deficient practice does not reoccur: An audit of all resident rooms and common area hot water taps will be completed by 12/26/2019 to ensure temperatures are between 105F and 120F. Person(s) responsible for implementing each step and/or Monitoring of corrective action to ensure the deficient practice will not reoccur: The Maintenance Director/Designee will randomly test water taps in common area and resident rooms weekly for 4 weeks then continue monthly to ensure hot water temperatures are between 105F and 120F.
Standard #:	22VAC40-73-870-A
Description:	Based on a tour of the facility physical plant the facility failed to ensure the interior of all buildings shall be maintained in good repair. Evidence #1: On 12/16/2019 with the facility Administrator, it was observed that the lower door frame located in the resident restroom of bedroom #26 contained brown areas that appeared to be rust. Evidence #2: On 12/16/2019 with the facility Administrator, it was observed that the facility memory care unit carpet was soiled and stained near the rear, left exit door.
Plan of Correction:	Steps to correct the noncompliance with the standards: 22VAC40-73-(8)-870-A A contractor has been hired to sand and paint the bathroom door frame in resident room # 26. A carpet cleaning service has been hired to address the carpet on the memory care unit. Measures/systematic changes put in place to ensure that the deficient practice does not reoccur: An audit of all resident bathrooms and in resident rooms will be completed by 12/26/2019 to ensure there are no signs of rust. All carpets in the building will be inspected and cleaned if needed by 12/26/2019. Person(s) responsible for implementing each step and/or Monitoring of corrective action to ensure the deficient practice will not reoccur: The Maintenance Director/Designee will inspect door frames and carpets throughout the building weekly for need for repair or cleaning.
Standard #:	22VAC40-73-930-A
Description:	Based on a test conducted of the facility call bell system the facility failed to ensure all assisted living facilities shall have a signaling device that is easily accessible to the residents in his bedroom or in a connecting bathroom that alerts the direct care staff the resident needs assistance. Evidence: On 12/16/2019 with the facility Administrator, the Licensing Inspector tested the call bell system in resident room #4 at approximately 9:47am. At approximately 9:55am after no response from the facility direct care staff, the facility Administrator inquired to staff regarding the unanswered call bell system. It was found that resident room #4 call bell system was not working.
Plan of Correction:	Steps to correct the noncompliance with the standards: 22VAC40-73-(8)-930-A Resident room # 4 was repaired by maintenance on 12/17/2019 and is now functioning properly. Measures/systematic changes put in place to ensure that the deficient practice does not reoccur: A 100 % audit of all resident rooms and common area call bell systems was completed on 12/16/2019 to ensure they are functioning properly. ED/DRC/nursing staff will be re-educated to call system and how to test for proper functioning of system. Date 12/26/201 9 12/26/201 9 12/26/201 9 12/26/201 9 12/26/201 9 PLAN OF CORRECTION INSPECTION DATE 12/16/2019 DOMINION VILLAGE WILLIAMSBURG 1104841 Person(s) responsible for implementing each step and/or Monitoring of corrective action to ensure the deficient practice will not reoccur: The Director of Resident Care/Designee will randomly test 10 call bells weekly for 4 weeks to start on 12/26/2019 and end on 1/16/2020 to ensure they are functioning properly.