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

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

Inspection Date: May 27, 2020 , May 28, 2020 and June 1, 2020

Complaint Related: No

Areas Reviewed:
22VAC40-73 PERSONNEL
22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
22VAC40-73 EMERGENCY PREPAREDNESS
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Article 1
Subjectivity
63.2 Facilities and Programs..
22VAC40-90 Background Checks for Assisted Living Facilities
22VAC40-90 The Sworn Statement or Affirmation
22VAC40-90 The Criminal History Record Report

Comments:
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia.

A renewal inspection was initiated on 5-27-20 and concluded on 6-1-20. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 31. The inspector e-mailed the administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, staff schedule, healthcare oversight, health department inspection, fire and emergency drills, oversight by dietitian/nutritionist and new hire since last renewal inspection ( date of hire, sworn statement/affirmation and criminal history record report.

Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:
Standard #: 22VAC40-73-260-A
Description: Based on document review and staff review, the facility failed to ensure the staff's maintain current certification from entities per the regulation.

Evidence:
1. During the remote inspection, a review of the first aid and cardiopulmonary resuscitation (cpr) document for staff #3 and staff #4 noted the training from an entity not in the regulation. However, the document noted having guidelines of one of the entity per the regulation.
2. The documents for first aid and cpr did not the training was conducted in a classroom setting.

Plan of Correction: Facility failed to ensure the staff?s maintain current certification from entities per regulation.
Staff #3 and #4 will receive classroom training for CPR and First Aid as soon as classroom training is available due to Covid-19 pandemic.
Current staff records will be reviewed by the DRC/designee to ensure that CPR and First Aid certification reflects
classroom training. Any staff not meeting this requirement will be scheduled for appropriate training as
soon as possible.
DRC or designee will ensure that training for CPR and first aid are taught by an entity recognized by the VA Dept.
of Social Services.

Standard #: 22VAC40-73-320-A
Description: Based on record review and staff interview, the facility failed to ensure the physical examination for one of three residents did not include all required information.

Evidence:
1. During the remote renewal inspection, the physical examination report for resident #1 did not include the following information: (a) any known allergies and description of the person's reactions and (b) a statement that specifies whether the individual is or is not capable of self-administering medications.
2. Staff #1 acknowledged the information was not on the resident's physical examination.

Plan of Correction: Facility failed to ensure the physical examination included all required information.
Resident #1 physical exam form will have an addendum added by the resident?s current physician to indicate
allergies and a description of the reaction and if the resident is capable of self-administering medications.
DRC will review all new admission history and physical examination to ensure all information is included.
DRC and BOM will be educated by the ED on correct history and physical form

0
7/3/202
0
to be used for new admissions.
Person(s) responsible for
implementation of each step and/or
monitoring preventative measures

Standard #: 22VAC40-73-450-C
Description: Based on record review and staff interview, the facility failed to two of three resident's individualized service plan (ISP) contained all assessed needs.

Evidence:
1. During the remote renewal inspection, a review of resident #1's uniformed assessment instrument (uai) dated 2-13-20 noted eating/feeding need assessed human help/supervision, however, the individualized service plan (ISP) dated 2-18-20 noted resident feeds self- no assistance needed. Bowel need assessed incontinent, weekly or more, however, the ISP did not include need assessed.
2. A review of resident #3's uai dated 3-3-20 noted toileting mechanical help/human help/physical assistance, however, the ISP dated 3-3-20 did not indicate what type of mechanical help is needed.
3. Staff #1 acknowledged all needs assessed were not on the resident's ISPs

Plan of Correction: Facility filed to ensure that ISP contained all assessed needs.
Resident #1 and #3 will have their ISP?s updated to reflect all assessed needs.
DRC to complete 100% audit of all ISP?s to ensure all assessed needs are documented.
All new and updated ISP?s will be reviewed by ED when completed x3 month. To begin June 25, 2020 and complete Sept. 25, 2020
DRC will be in-service by RDH on documentation as assessed needs on ISP.

Standard #: 22VAC40-73-680-H
Description: Based on record review and staff interview, the facility failed to medication administration record (mar) included the documentation of medication/treatment for a resident.

Evidence:
1. During the remote inspection, a review of resident #3's April 2020 medication administration record (mar) noted Venelex B7 ointment for wound care. Further review of the mar, there were no signature or initials of the treatment being completed. A review of the physician's order signed and dated 3-2-20 noted the treatment order for Venelex 87.
2. Staff #1 acknowledged the mar did not document staff's administration of resident #1's ointment for wound care on the April 2020 mar.

Plan of Correction: Facility failed to include the documentation of medication/treatment for a resident on MAR
DRC will request Venelex by discontinued for resident#3.
DRC will review medication administration record weekly to ensure documentation of all medication/treatment beginning June 27th through July 27th, then monthly through Sept. 25, 2020
DRC will educate staff on the medication management plan specific to documentation on the MAR

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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