VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Dominion Village at Poquoson
531 Wythe Creek Road
Poquoson, VA 23662
(757) 868-0335

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

Inspection Date: Feb. 25, 2020 and Feb. 26, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

An unannounced monitoring inspection was conducted on 2-25-20 (ar 07:30 am/dep 17:30 pm) and 2-26-20 (ar 09:00 am/dep 14:30 pm). The census on 2-25-20 was 33. A medication pass was observed on 2-25-20, resident records review, emergency preparedness, safe, secure unit tour and meal observation,first aid kit, staff and resident interviews. Staff and resident record reviewed on day 2, water temperature, healthcare oversight, nutrition and pharmacy documents reviewed with administrator. An exit interview was conducted on both days with the administrator and the acknowledgement form signed. Comment: All pharmacy recommendations should be forwarded to the physician, suggest the staff date of hire be accurately documented. Also suggested clarity for resident rounding, more specific time needed. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendars of receipt (3-19-20). Should you have questions you may contact the licensing inspector at 757-439-6815.

Violations:

Standard #:	22VAC40-73-310-H
Description:	Based on record review and staff interview, the facility failed to ensure psychotropic treatment plan for a resident was completed. Evidence: 1. On 2-25-20 during a review of resident #3's record with staff #1, the psychotropic treatment plan for Risperdal was not signed and dated by the prescriber. 2. Staff #1 acknowledged the treatment plan for the aforementioned medication treatment plan was not signed by the prescriber.
Plan of Correction:	Resident?s psychotropic treatment plan was resent to physician with follow up phone call. Treatment plan was signed and returned to the facility on 3.9.2020 DRC to complete 100% audit to ensure all residents with psychoactive medications have treatment plan in place, with physician signature. DRC will review all psychoactive medications monthly for 3 months to ensure treatment plan is in place to begin 4.1.2020 and end 6.30.2020
Standard #:	22VAC40-73-320-A
Description:	Based on record review and staff interview, the facility failed to ensure the resident's physical examination included accurate information. Evidence: 1. On 2-26-20 during a review of resident #7's physical examination document, the physical dated 11-12-19 indicated the resident was ambulatory. Further review of the record noted the resident was date of admission was 11-12-19 and the resident's placement for the safe, secure unit was also dated 11-12-19. 2. Staff acknowledged the physical examination for resident #7 indicated the resident as ambulatory.
Plan of Correction:	DRC/designee to review current resident files on the safe, secure unit to validate accurate information on resident physical exam to indicate that resident is non-ambulatory. To be completed by 3.31.2020 DRC, BOM and ED to be re-educated by the RDH with regard to accurate information on the physical exam form for residents who move in to the safe, secure unit.DRC/designee will audit all new move ins to the safe, secure unit monthly for 3 months to ensure accuracy of information on the physical exam form. To being 4/1/2020 and end 6/30/2020
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) included all required information. Evidence: 1. On 2-25-20 during a review of resident #3's individualized service plan (ISP, dated 12-31-19) with staff #1, the resident's date outcome achieved for physical therapy and occupational therapy was not included. Services were completed 2-6-20. 2. Staff #1 and #2 acknowledged therapy outcome dates were not included on resident #3's ISP. 3. On 2-26-20, a review of resident #6's ISP with staff #1 and #2, the uniformed assessment instrument (UAI) dated 3-18-19 was blank for bowel need; however; the ISP dated 4-23-19 noted incontinent less than weekly. 4. On 2-26-20, a review of resident #7's ISP dated 12-12-19, did not indicate an assistive device for walking. However, the UAI dated 11-12-19 noted mechanical help for walking. 5. Staff #1 and #2 acknowledge the ISP and UAI do not agreement for residents #6 and #7.
Plan of Correction:	Resident #3 ISP was updated on 3/9/2020.Resident # 6 ISP and UAI were updated on 3/9/2020 Resident #7 ISP was updated to reflect the use of hand rails at times 3/9/2020 DRC will be re-educated by the ED regarding including all required information in a resident?s ISP ED will review all UAI?s and ISP?s after completion to ensure all required information is included weekly for 4 weeks then monthly for 2 months. To being 4/1/2020 and end 6/30/2020.
Standard #:	22VAC40-73-680-I
Description:	Based on record review and staff interview, the facility failed to ensure the medication administration record (MAR) included all of the required information. Evidence: 1. On 2-25-20 during the medication observation pass with staff #4, the February 2020 medication administration record (MAR) for resident #3 did not include diagnosis for the following medications: (a) Afrin , Risperdal and (c) Aricept. 2. Staff #4 acknowledged the AR for resident #4 was missing diagnosis for the aforementioned medications on 2-25-20.
Plan of Correction:	Resident # 3s orders will be clarified to include diagnosis or indication for use by 3.31.2020. DRC will educate nursing staff to obtain diagnosis when new order is received. DRC will review all new orders for diagnosis weekly x8 weeks and monthly x2 months. To begin 4.1.2020 and end 6.30.2020
Standard #:	22VAC40-73-680-M
Description:	Based on record review and staff interview, the facility failed to ensure medications ordered for PRN administration was available, properly labeled an properly stored at the facility for a resident. Evidence: 1. On 2-26-20 during the medication observation pass with staff #4, the PRN, milk of magnesia, for resident #3 was not available on the medication cart. Staff #4 searched both medication carts but did not locate the medication 2. Staff #4 acknowledged the medication for resident #3 was not available in the facility on 2-26-20.
Plan of Correction:	Medication carts will be audited to ensure all PRN medications ordered are available by 3.31.2020 RMAs and LPNs will be re-educated to the medication management plan with regard to availability of medications by DRC. DRC or designee will audit medication cart to ensure all PRN medications are available weekly x4 weeks, then monthly x 3 months To begin 4.1.2020 and end 6.30.2020