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: March 30, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

A Representative with the Division of Licensing conducted an unannounced mandated renewal inspection on 03/30/2022 from 11:00am to 5:00pm. At the point of entrance the facility Administrator was present and assisted with the inspection. The Licensing Inspector observed the facility physical plant, observed the facility emergency food supply, observed 6 resident and 4 staff records and reviewed additional facility documentation for compliance. 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 #:	22VAC40-73-250-D
Description:	Based on staff record review 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 #3 on 03/30/2022, staff record #3's last tuberculosis assessment was completed on 02/02/2019.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review the facility failed to ensure the comprehensive individualized service plan shall include the expected outcome and time frame for expected outcome. Evidence: While observing resident #4's record on 03/30/2022, resident #4's Individualized Service Plan did not contain outcome and time frame for expected outcome.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-550-G
Description:	Based on 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 resident's, his legal representative's or responsible individual's, or staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the staff person's record. Evidence: While reviewing staff record #1 and #2 on 03/30/2022, the Licensing Inspector observed staff records #1 and #2 did not contain a review of resident rights nor was the facility able to provide.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation of the facility physical plant the facility failed to ensure the storage area shall be locked. Evidence#1: While observing the facility physical plant with the facility Administrator the Licensing inspector observed, "Silver Centrum Men Plus" in resident #7's apartment. The medication was not locked in a storage unit inside resident #7's apartment.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-A
Description:	Based on observation of the facility physical plant, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair. Evidence: While observing the facility physical plant with the facility Administrator the following areas were found to not be maintained in good repair: 1- The secure unit memory care gardening area contained broken wood 2- The secure unit carpet was stained 3- the secure unit bottom of the hall walls were scratched and faded 4- The secure unit bottom of sink, doors and toilets were brown and appeared to be rusted
Plan of Correction:	Not available online. Contact Inspector for more information.