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: June 13, 2022 and June 17, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Renewal Date(s) of inspection the licensing inspector was on-site at the facility for each day of the inspection: 6/13/22 & 6/17/22 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 30 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 7 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing Inspectors observed activities, meals and medication passes during the inspection. Additional Comments/Discussion: n/a An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.

Violations:

Standard #:	22VAC40-73-40-B-4
Description:	Based on observation and interview with staff, the facility failed to ensure certain documents related to the terms of the license were posted on the premises of the licensed facility, including the most recently issued findings of the most recent inspection of the facility. Evidence: During the on-site inspection on 6/13/22, the most recent findings from the inspection dated 5/17/21 were not posted.
Plan of Correction:	Steps to correct the noncompliance with the standard: Current inspection along with last inspection put back in foyer. ED to that inspection remains in place and remains current. ED to also keep in binder in main lobby as a backup. Corrected on site Measures to prevent the noncompliance from occurring again: BOM and ED will check monthly to ensure inspection remains posted and current. Person(s) responsible for implementation of each step and/or monitoring preventative measures ED and BOM will check monthly and ongoing.
Standard #:	22VAC40-73-260-C
Description:	Based on staff interview and observation the facility failed to have a listing of all staff who have current certification in First Aid and CPR posted in the facility readily available to staff. Evidence: During the on-site inspection on 6/13/22, there was not a posting of staff members who had current certification in First Aid and CPR.
Plan of Correction:	Steps to correct the noncompliance with the standard: CPR/First aid spreadsheet is will be posted and available. Corrected on site Measures to prevent the noncompliance from occurring again: HWD will set up training and keep spreadsheet current Person(s) responsible for implementation of each step and/or monitoring preventative measures HWD and/or ED will conduct audit. HWD to spot check to ensure spreadsheet remains posted.
Standard #:	22VAC40-73-290-B
Description:	Based on observation, the facility failed to ensure the posting of the name of the current on-site person in charge. Evidence: During the on-site inspection on 6/13/22, the easel that contained the on-site person in charge was blank. Later during the inspection, the LI observed Staff # 7 updating the easel.
Plan of Correction:	Steps to correct the noncompliance with the standard: Staff in charge will be posted daily on easel in front lobby. Corrected on site Measures to prevent the noncompliance from occurring again: 1:1 training with night shift person in charge conducted to ensure updates are done. Person(s) responsible for implementation of each step and/or monitoring preventative measures Night charge team member to update easel nightly, LED and/or MOD to check daily to ensure accuracy
Standard #:	22VAC40-73-610-B
Description:	Based on observations made during the on-site inspection on 6/17/22, the facility failed to document the menu substitutions on the posted menu. Evidence: During the on-site inspection on 6/17/22, the posted menu listed green salad, battered fried fish or roast beef, onion roasted potatoes, Normandy blend, baked roll. Meat balls, spinach, macaroni and cheese, and a roll were observed on each resident?s plate. The change was not made on the posted menu.
Plan of Correction:	Steps to correct the noncompliance with the standard: FSD will train dietary team on any substitutions and/or changes to menu be updated accordingly and reflected on posted menu Measures to prevent the noncompliance from occurring again: FSD to have all dietary team members trained on procedure Person(s) responsible for implementation of each step and/or monitoring preventative measures FSD to monitor posted menu each week to ensure any updates were noted. ED and/or BOM to spot check
Standard #:	22VAC40-73-610-B
Description:	Based on observations made during the inspection of the facility, the facility failed to have the menu for the current week posted. Evidence: 1. During the on-site inspection on 6/13/22, there was no posted menu in a place conspicuous to residents. 2. Staff # 8 acknowledged there was no weekly menu posted.
Plan of Correction:	Steps to correct the noncompliance with the standard: FSD posted current weekly menu in both AL and MC. Measures to prevent the noncompliance from occurring again: FSD to print and post menu each week on AL and MC. FSD to ensure menu is printed so that another dietary team member can access and post if FSD is not in community. Person(s) responsible for implementation of each step and/or monitoring preventative measures FSD will keep binder of upcoming weekly menus for easy access. FSD will ensure menu is kept current and posted. ED and BOM to spot check for compliance
Standard #:	22VAC40-73-680-I
Description:	Based on documentation review, the facility failed to include all required documentation on the Medication Administration Record (MAR). Evidence: 1. Resident # 3 had a physician?s order for Acetaminophen 500 mg. Take 2 tablets (1000mg) by mouth three times daily for pain. The medication administration spaces for the following dates and times were blank and there was no documentation on the back of the MAR: 5/7/22 3pm, 11pm 5/8/22 3pm , 11pm 5/27/22 3pm, 11pm 5/28/22 7am, 3pm, 11pm 5/29/22 7am, 3pm, 11pm 5/30/22 3pm 5/31/22 3pm, 11pm 2. Resident #3 had a physician?s order for Biotin 1000 mcg. One tablet by mouth every day for supplement. The medication administration spaces for the following dates and times were blank and there was no documentation on the back of the MAR: 5/28/22 8am 5/29/22 8am 3. Resident #3 had a physician?s order for Eliquis 2.5 mg. One tablet by mouth twice daily for prevention of blood clot. The medication administration spaces for the following dates and times were blank and there was no documentation on the back of the MAR: 5/28/22 7am, 8pm 5/29/22 7am, 8pm 5/31/22 8pm 4. Resident #3 had a physician?s order for Levothyroxine Sodium 75mg tablet. One table to be given by mouth every day for hypothyroidism. The medication administration spaces for the following dates and times were blank and there was no documentation on the back of the MAR: 5/28/22 7am 5/29/22 7am 5. Resident #4 had a physician?s order for Acetaminophen 500 mg. Two tablets (1000 mg) by mouth three times daily for osteoarthritis. The medication administration spaces for the following dates and times were blank and there was no documentation on the back of the MAR: 5/12/22 4pm 5/31/22 4pm 6. Resident #4 had a physician?s order for Trazadone 50 mg. One tablet by mouth 2 times a day for behavioral disorders associated with dementia. The medication administration spaces for the following dates and times were blank and there was no documentation on the back of the MAR: 5/12/22 4pm 5/31/22 4pm
Plan of Correction:	Steps to correct the noncompliance with the standard: HWD to train and review all LPN and RMA?s on new ALIS system and will review proper documentation. Measures to prevent the noncompliance from occurring again: HWD will randomly spot check MAR weekly. HWD and audit MAR?s on a monthly basis to ensure compliance Person(s) responsible for implementation of each step and/or monitoring preventative measures HWD will have trainings completed with team by 7/30/2022. HWD to review weekly and as needed. ED to review periodically for upkeep.
Standard #:	22VAC40-73-870-A
Description:	Based on observation and interview, the facility failed to maintain the interior and exterior of the building in good repair. Evidence: During a tour of the facility on 6/13/22, the following areas were observed to be in need of repair: 1. There were exposed wires from an alarm system in the main hallway on the memory care unit. 2. The vinyl floor was peeling in a bedroom on the memory care unit. 3. Staff # 8 acknowledged items listed above were in need of repair.
Plan of Correction:	Steps to correct the noncompliance with the standard: 1. ESD repaired alarm system wires 6/13/22 corrected on site 2. Flooring in room 12 on memory care has been replaced. Measures to prevent the noncompliance from occurring again: ESD will correct or contact contracted outside company for any repairs, daily walk through of community to oversee upkeep. Person(s) responsible for implementation of each step and/or monitoring preventative measures ESD to ensure daily walk throughs are conducted ED to ensure daily walkthrough by ESD and another management team member take place daily, any findings to be discussed in stand up and to ensure follow up has been completed