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: April 25, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Other/self-report/complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/25/2023 8:19am- 4:14pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 3/1/2023 regarding allegations in the area(s) of: Resident Care and Related Services An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at (757) 670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-460-D
Complaint related:	Yes
Description:	Based on documentation and record review, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises. Evidence: 1. On 3/1/2023 at 4:40pm two residents of the safe, secure, environment were able to walk out of the facility and walk down the road to the neighborhood behind the facility. 2. Staff #1 acknowledged the residents eloped from the facility through a side exit during renovations of the unit.
Plan of Correction:	Steps to correct the noncompliance with the standard: Remodel completed, door alarms were checked and reset. Hourly head counts Measures to prevent the noncompliance from occurring again: Charge nurse to check door alarms each shift. ESD will ensure compliance by checking doors/alarms weekly. ED and HWD to spot check. Hourly rounds to continue by caregivers. All team members to assist in programming to keep residents engaged. Elopement Drill conducted to review with team. Training on elopement and prevention 3/3/2023 Person(s) responsible for implementation of each step and/or monitoring preventative measures ESD will check alarms weekly and ED to spot check.