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: Feb. 26, 2020 and March 4, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

Two Licensing Inspectors with the Division of Licensing conducted an unannounced, mandated monitoring inspection on 02/26/2020 at approximately 1:30pm and on 03/04/020 from approximately 6:45pm. The facility Administrator was available for a portion of the inspection and staff in charge assisted with completion on the Inspection. During the Inspection Licensing Inspectors reviewed, 8 resident and 4 staff records, observed the facility medication administration pass, physical plant, emergency food supply, resident activities, meals and interviewed staff and residents. During the Inspection a repeat violation was cited. Areas of non-compliance are found within this violation notice.Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to me within 10 calendar days from today. 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 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please contact the facility Licensing Inspector Kimberly Rodriguez at 757-586-4004 or by email at kimberly.rodriguez@dss.virginia.gov for additional questions or concerns.

Violations:

Standard #:	22VAC40-73-100-A
Description:	Based on observation and the facility failed to ensure the assisted living facility implemented an infection control program addressing the surveillance, preventions, and control of disease and infection that is consistent with the federal Centers for Disease Control and Prevention (CDC) guidelines and the federal Occupational Safety and Health Administration (OSHA) bloodborne pathogens regulations. Evidence #1: On 03/04/2020 while observing the facility dining room during the dinner meal time, Licensing Staff observed direct care staff seated between two residents requiring assistance with feeding. The direct care staff member, wearing gloves peeled shrimp with gloved hands, then proceeded to feed resident #5. The direct care saff using the same pair of gloves devined shrimp and fed resident another resident seated at the same table who also required assistance with feeding. Evidence #3: The direct care staff was observed pacing a pager in pocket, removing the dishes from other tables then returning to the two members to assist with feeding.
Plan of Correction:	Steps to correct the noncompliance with the standards: 22VAC40-73-(8)-870-A Staff members identified as working during dinner on 3/4/2020 will be re-educated to infection control practices during meal service. Measures/systematic changes put in place to ensure that the deficient practice does not reoccur: Current LPNs, RMAs and RSAs will be re-educated to infection control practices with a focus on infection control during meal service. Staff will be monitored by Director of Resident Care/designee for compliance with infection control in the dining room at various meals 3 times a week for 4 weeks then 2 times a week for 4 weeks then 1 time a week for 4 weeks to start on 6/1/2020 and end on 8/31/2020. Start date will depend on reopening of communal dining areas. 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 is responsible for compliance with infection control practices.
Standard #:	22VAC40-73-210-B
Description:	Based on record review and staff interview, the facility failed to ensure direct care staff attend at least 18 hours of training annually. Evidence #1: On 3/04/2020 during a review of staff #3 record, the staff's record did not contain 18 hours of the required annual training. Staff date of hire was indicated at 5/10/2013 and promotion to activities person for safe, secure unit on 4/24/2017. Staff #3's record did not include the required two (2) hours of infection control; hours noted included dementia 6 hours and ISP training 6.0 hours. Evidence #2; The Licensing Inspectors spoke with staff #3 to determine if staff had copies of training course not in the record and staff did not have additional training certificate/documentation of required training.
Plan of Correction:	Steps to correct the noncompliance with the standards: 22VAC40-73-(3)-210-B Staff #3 will have the required training hours yearly and it will be documented in staff file. Measures/systematic changes put in place to ensure that the deficient practice does not reoccur: BOM/designee will audit direct care staff files to ensure all required training hours are documented. BOM will be re-educated by the Executive Director to the required tracking of staff inservice hours to include mandatory training hours and specific topics. In-service schedule will be followed to ensure direct care staff members attend 18 hours per year. Twice per year (June and December) staff files will be reviewed by the BOM/designee, to monitor hours and content of training. Person(s) responsible for implementing each step and/or Monitoring of corrective action to ensure the deficient practice will not reoccur: Director of Resident Care and Executive Director are responsible for planning and implementing training schedule. BOM is responsible for maintaining documentation of trainings in staff files.
Standard #:	22VAC40-73-250-D
Description:	Based on staff record review the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility shall submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form conistent with it. Evidence: On 03/04/2020 while reviewing staff #4's record hired on 12/24/2019, it was observed staff #4's record did not contain results of a risk assessment documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it.
Plan of Correction:	Steps to correct the noncompliance with the standards: 22VAC40-73-(3)-250-D Staff #4 will have current documentation of tuberculosis risk assessment in file. Measures/systematic changes put in place to ensure that the deficient practice does not reoccur: BOM will audit all staff hired after Jan 1 2020 have documentation of tuberculosis risk assessment in their file. The BOM will be re-educated by the Executive Director to the requirement for documentation of tuberculosis risk assessment prior to orientation. All newly hired staff will be required to provide documentation of a tuberculosis risk assessment to document the absences of tuberculosis prior to attending orientation. ED/Designee will audit all new hire files for tuberculosis risk assessment documentation monthly for 3 months to begin 6/1/2020 and end 8/31/2020. ED/Designee will audit all new hire files for tuberculosis risk assessment documentation monthly for 3 months to begin 6/1/2020 and end 8/31/2020. Person(s) responsible for implementing each step and/or Monitoring of corrective action to ensure the deficient practice will not reoccur: The Business Office Manager will ensure staff members do not begin orientation until tuberculosis risk assessment is provided.
Standard #:	22VAC40-73-325-A
Description:	Based on record review and staff interview, the facility failed to ensure a fall risk rating was completed by the time the comprehensive individualized service plan (ISP) was completed. Evidence #1: On 3/04/2020 during a review of resident #1's record, the individualize service plan (ISP) indicated fall risk need dated 7/23/2018. However, the record did not contain documentation of a fall risk rating. The resident's date of admission was noted as 7/23/2018. The uniformed assessment instrument (UAI's) dated 7/19/2018, 8/23/2018, 3/25/2019, and 5/18/2019 indicated resident #1 was assessed at the assisted living level of care. Evidence #2: On 3/04/2020 resident #2's individualized service plan indicated fall risk need dated 11/02/2018, however, the record did not contain documentation of a fall risk rating. The resident's date of admission was noted as 11/12/2018. The UAI's dated 11/07/2018, 12/12/2018, and 11/12/2019 indicated resident #2 was assessed of the assisted living level of care. Evidence #3: Staff #2 was not able to locate the fall rating documents for resident #1 and #2.
Plan of Correction:	Steps to correct the noncompliance with the standards: 22VAC40-73-(5)-325-A Resident #1 and Resident #2 have a current fall risk rating in their chart. Current resident charts and administrative files will be audited for Fall Risk Evaluation with updates made as appropriate with ISPs reviewed and updated as needed by the DRC/designee. Measures/systematic changes put in place to ensure that the deficient practice does not reoccur: The Director of Resident Care will be re-educated by the Regional Director of Health Care to the requirement for fall risk rating prior to the completion of the comprehensive ISP. Current LPNs will be re-educated to completion of fall risk rating within 30 days of admission. The Director of Resident Care will review charts of residents who fell or who were newly admitted to the community weekly for 4 week then 2 times a month for 2 months to ensure completion of a fall risk rating. To begin on 6/1/2020 and complete on 8/31/2020. Person(s) responsible for implementing each step and/or Monitoring of corrective action to ensure the deficient practice will not reoccur: Director of Resident Care will be responsible for updating Fall Risk assessments. Executive Director will be responsible for monitoring compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure the resident's individualized service plan (ISP) included all assessed needs. Evidence #1; On 3/04/2020 during a review of resident #1's record, the individualized service plan (ISP) dated 5/13/2019 indicated the resident as a "full code", however, the record included a "Do Not Resuscitate" document signed and dated 6/14/2019 by physician. The social data also indicated resident to be a "full code". Evidence #2: Staff #2 acknowledged the resident's record contain a "Do Not Resuscitate" Document.
Plan of Correction:	Steps to correct the noncompliance with the standards: 22VAC40-73-(6)-450-C Resident #1 ISP has been updated to include the correct code status DNR. Current resident charts will be audited by the Director of Resident Care/designee to ensure that the resident?s current code status is correctly reflected on the ISP. Measures/systematic changes put in place to ensure that the deficient practice does not reoccur: Current LPNs and RMAs will be re-educated regarding the process for notification of a change in a resident?s code status. Code status will be reviewed as part of the Level of Care assessment tool completed by the Director of Resident Care/designee every 6 months with the ISP updated as needed. Person(s) responsible for implementing each step and/or Monitoring of corrective action to ensure the deficient practice will not reoccur: Director of Resident Care will be responsible for monitoring proper documentation of code status changes.
Standard #:	22VAC40-73-550-G
Description:	Based on observation and staff record review, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each staff person. Evidence of this review shall be the staff person written acknowledgement of having been informed, which shall include the date of the review and shall be filed in the staff person' s record. Evidence #1: On 03/04/2020 while observing the facility dining room during meals, Licensing staff observed staff #5 speaking with two residents in a manner that did not reflect courtesy, respect, and consideration of a person of worth, sensitivity and dignity as outlined in 63.2-1808, Rights and responsibilities of residents of assisted living facilities. Evidence #2: Licensing Staff observed staff #5 cleaning the facility dining room at the end of the dinner meal while resident #4 was present in the dining room. Staff #5 rolled the resident in the wheelchair outside the facility dining room and immediately closed the dining room doors in a manner that did not reflect courtesy, respect, and consideration as a person of worth, sensitivity and dignity as outlined in 63.2-1808, Rights and responsibilities of residents of assisted living facilities. Evidence #3: While reviewing staff #5's record, documentation showed the last review of resident rights and responsibilities was dated 02/24/2017.
Plan of Correction:	Steps to correct the noncompliance with the standards: 22VAC40-73-(6)-550-G Staff Member #5 will be re-educated by the Executive Director to Resident Rights and Responsibilities of Adults in Assisted Living Facilities to include treating residents with respect and dignity. Measures/systematic changes put in place to ensure that the deficient practice does not reoccur: Current staff members will review Rights and Responsibilities of Adults in Assisted Living Facilities by 5/31/2020 and annually thereafter. Staff files will be reviewed by the BOM/designee 2 times a year in June and December to ensure yearly review of Resident Rights and Responsibilities of Adults in Assisted Living Facilities. Person(s) responsible for implementing each step and/or Monitoring of corrective action to ensure the deficient practice will not reoccur: Business Office Manager will be responsible for auditing files and contacting staff who need to review Rights and Responsibilities of Adults in Assisted Living Facilities. Executive Director will monitor and ensure this is completed by 5/31/2020.
Standard #:	22VAC40-73-650-A
Description:	Based on resident record review, staff interviews and photos taken the facility failed to ensure no diet shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Evidence #1: On 03/04/2020 Two Licensing Inspectors observed the facility dining room during the dinner meal time. Licensing inspectors asked resident #3 if anything was wrong as the resident was not eating, resident #3 responded,"I have an allergy to everything on the menu." Licensing Staff interviewed staff #5 whom informed the resident was provided soup. Staff #5 provided Licensing Staff a can of soup that was provided for the residents meal. Based on resident #3's medication administration record signed by the physician on 02/10/2020, resident #3 had an allergy to Gluten and agg. Evidence #2: As evidenced by the photos shown the soup served and consumed by resident #3 contained wheat and egg. Evidence #3: On 03/04/2020 Licensing Staff observed resident #5 was assisted with feed of whole fried shrimp, boiled potato, cole slaw and roll. According to the residents medication administration dated 12/31/2019 and Individualized Service Plan last updated 02/16/2019 resident #5's diet was mechanical soft with nectar thick liquieds (no straw). Resident #5 did not receive nor consume the diet as ordered by the resident physician as evidenced by photos provided.
Plan of Correction:	Steps to correct the noncompliance with the standards: 22VAC40-73-(6)-650-A Diets for residents referenced in violations were reviewed with dietary staff on 3/5/2020. Residents referenced in violations have received the correct diet. (3/6/2020) Dietary staff members were re-educated on 3/5/2020 with regard to a mechanical soft diet. Care staff members were re-educated on 3/6/2020 with regard to these residents? diets and the importance of following all resident diet orders.(3/6/2020) Measures/systematic changes put in place to ensure that the deficient practice does not reoccur: Director of Resident Care/ designee and Dining Services Director/designee discuss diet changes at weekly Resident Risk Meetings with Executive Director/designee in attendance to ensure diet changes are followed properly. Director of Resident Care and Dining Services Director will communicate changes with their respective staff members. Staff will be informed when a diet change is made utilizing the Diet Notification form. Person(s) responsible for implementing each step and/or Monitoring of corrective action to ensure the deficient practice will not reoccur: Director of Resident Care and Dining Services Director will be responsible for managing their roles in diet compliance. Executive Director will address diets as part of the weekly Resident Risk Meetings. _________________________________
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation of the facility secured unit and photos takes the facility failed to ensure the storage area shall be locked. Evidence: On 02/26/2020 with staff #1, it was observed that the facility secure unit contained 11 bottles of Ensure supplement in the unlocked refrigerator located in the dining room.
Plan of Correction:	Steps to correct the noncompliance with the standards: 22VAC40-73-(6)-660-A-1 Ensure has been moved to the Nurse?s Station in Assisted Living. Measures/systematic changes put in place to ensure that the deficient practice does not reoccur: Current LPNs RMAs, and RSAs will be re-educated to the storage of dietary supplements. The Bridge to Rediscovery Director/designee will monitor the refrigerator in the Bridge to Rediscovery kitchen daily to ensure compliance with storage on the Bridge to Rediscovery. Person(s) responsible for implementing each step and/or Monitoring of corrective action to ensure the deficient practice will not reoccur: Bridge to Rediscovery Director and Director of Resident Care will monitor the refrigerator for proper usage. Executive Director will perform weekly checks to ensure proper storage of supplements.
Standard #:	22VAC40-73-870-A
Description:	Based on observation of the facility physical plant and photos taken, the facility failed to ensure the interior of the building shall be maintained in good repair. Evidence: On 02/26/2019 with staff #1 the following areas were observed not in good repair as evidenced by photos shown. 1. Resident shared bathroom in room #7 and #8 was peeling at the base. 2. Resident restroom in room #3 was rusted at the base of the door frame. 3. The facility secure unit carpet was visibly stained and soiled. 4. Resident room #13 door frame was rusted at the base. 5. Resident room #13 sliding closet door was off the hinge. 6. The facility secure unit courtyard contained a broken wooden flower bed. 7. The facility secure unit courtyard contained broken gutter. 8. The facility secure unit courtyard contained a broken table. 9. The front entrance to the facility did not open when pushing the handicap accessible button to open the door automatically.
Plan of Correction:	Steps to correct the noncompliance with the standards: 22VAC40-73-(8)-870-A Room #3?s door frame will be repaired and painted. Carpet on the Memory Care Unit will continue to be steam cleaned monthly. Measurements for replacement flooring were completed on 3/11/2020 with installation to occur once the community is open to non-essential personnel. Room #13 will have the door frame repaired and painted. Room #13?s sliding door was fixed on 2/27/2020 Broken flower bed, broken gutter, and broken table in the secured courtyard were removed on 2/27/202 by Maintenance Director. The handicap accessible door was inspected by contractors on 2/26/2020 and new sensors were installed on 2/28/2020. Measures/systematic changes put in place to ensure that the deficient practice does not reoccur: All door frames in resident rooms and bathrooms in the community will be inspected, evaluated for damage, and scheduled for repair by Maintenance Director or outside contractor as appropriate. The inspection will be completed by 5/8/2020 and repairs will be completed by 5/31/2020. Once inspected and repaired, maintenance will do monthly room and bathroom checks to monitor peeling paint or rust around door frames. Once replaced, the carpet will continue to be vacuumed daily and steam cleaned by housekeeping monthly and spot cleaned as needed. If replaced with vinyl floor, it will be mopped at least every other day and spot cleaned as needed. Sliding doors will be reviewed by Maintenance monthly during room inspections and repaired on an as needed basis. Secured courtyard will be inspected before opened for residents. Courtyard will also be inspected weekly for damaged items by Bridge to Rediscovery Director. Handicap accessible doors are tested weekly for proper functioning by Maintenance Director. Person(s) responsible for implementing each step and/or Monitoring of corrective action to ensure the deficient practice will not reoccur: The Maintenance Director will be responsible for the inspection and repair of all resident rooms and bathrooms. Executive Director and Maintenance Director will be responsible for working with vendor to install new carpet or vinyl. Housekeeping and care staff will be responsible for maintaining clean flooring. Maintenance Director will be responsible for repairing closet doors. All staff are responsible for reporting broken or malfunctioning equipment. Maintenance Director and Bridge to Rediscovery Director will be responsible for maintaining the secured courtyard. Maintenance Director will report malfunctions with front door to Executive Director and contact repair services as needed. All staff members are responsible for reporting malfunctioning equipment to management.
Standard #:	22VAC40-73-870-E
Description:	Based on observation of the facility physical plant and photos taken the facility failed to ensure all fixtures including sinks shall be kept clean and in good repair. Evidence: On 02/26/2020 with staff #1, it was observed that resident room #3 on the facility secure unit the piping under the sink and the wood was wet to touch and contained a black substance as evidenced by photos shown.
Plan of Correction:	Steps to correct the noncompliance with the standards: 22VAC40-73-(8)-870-E Sink was repaired and cabinet cleaned day of inspection (2/24/2020) by Maintenance Director. Measures/systematic changes put in place to ensure that the deficient practice does not reoccur: The Maintenance Director will complete an audit of all sinks and faucets in resident bathrooms to monitor for leaking or moisture with repairs completed as needed. Monthly audit of all sinks and faucets will occur to monitor for leaking or moisture by Maintenance Director will repairs completed as needed. Person(s) responsible for implementing each step and/or Monitoring of corrective action to ensure the deficient practice will not reoccur: Maintenance Director will be responsible for the monitoring of malfunctioning sinks and pipes. Maintenance Director will repair damaged fixtures and inform Executive Director of leaks.