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: April 13, 2021 and April 14, 2021

Complaint Related: No

Areas Reviewed:

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 EMERGENCY PREPAREDNESS

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 04/13/2021 and concluded on 04/14/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census. The inspector emailed the Administrator a list of item required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, staff schedules , Fire Inspection, Health Department Inspection Report and additional documentation provided by the facility. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-210-B
Description:	Based on staff record reviews, the facility failed to ensure In a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually. Evidence #1: While reviewing staff #2's, hired by the facility on 1-27-2020, the record did not contain any annual training. Evidence: #2 While reviewing staff #3's record hired by the facility on 07-09-2012, the last date of annual training completed was 12-04-2019.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-250-D
Description:	The facility failed to ensure each staff person or household member required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free 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. Evidence: While reviewing staff record #2 and #3 documentation provided evidenced the last tuberculosis screening was completed on 01/02/2020 and 01/15/2020.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-260-A
Description:	Based on record review the facility failed to ensure each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment. Evidence: Staff record #2, hired by the facility on 01-27-2020 as a Direct Care staff did not contain First Aide training.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-E
Description:	The facility failed to ensure the individualized service plan shall be signed and dated by the resident or his legal representative. Evidence: While reviewing resident record #1 and #2, documentation provided for the residents individualized service plan, did not contain signatures provided by the resident or legal representative.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-550-G
Description:	Based on record review the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person as evidenced of this review shall be the resident's, his legal representative's or responsible individual's, written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's or staff person's record. Evidence: While reviewing resident records #1, #2 and #3, all three records did not contain signed resident rights.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-970-A
Description:	Based on resident record review the facility failed to ensure fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). Evidence: While reviewing the fire and emergency evacuation drills during the quarter of February to April, 2021. The facility did not provide a fire drill for the month of March 2021. In addition the facility did not provide a fire drill all required shifts.
Plan of Correction:	Not available online. Contact Inspector for more information.