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 and May 11, 2023

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/11/2023 from 8:19am ? 4:14 pm and 5/11/2023 from 7:45 am ? 9:20 am 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: 40 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Licensing Inspector observed a meal, inspected the facility and conducted resident interviews. Additional Comments/Discussion: 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. T he 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 E. Walker, Licensing Inspector at (757)670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1100-A
Description:	Based on resident record review, the facility failed to ensure that prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the written approval of one of the following persons, in the following order of priority: The resident, if capable of making an informed decision; a guardian or other legal representative for the resident if one has been appointed; a relative who is willing to take responsibility to act at the resident?s representative; an independent physician who is skilled and knowledgeable in the diagnosis and treatment of dementia. Evidence: The record for Resident #2 did not contain prior written approval from the resident or their guardian or representative before the resident was placed in the safe secure environment.
Plan of Correction:	Steps to correct the noncompliance with the standard: Authorization for approval of Special care unit obtained from POA Measures to prevent the noncompliance from occurring again: HWD and/or BOM will utilize move in checklist to ensure documentation received and signed prior to admission to MC. MCD and HWD to audit MC files to ensure compliance Person(s) responsible for implementation of each step and/or monitoring preventative measures. BOM or designee to obtain prior to admission. MCD/HWD to review with each admission. ED to spot audit for compliance.
Standard #:	22VAC40-73-1110-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that prior to admitting a resident within a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator or designee shall determine whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident?s file. Evidence: The record for Resident #1 did not contain documented evidence of the licensee, administrator, or designee?s justification for the decision to place the resident in the safe, secure environment.
Plan of Correction:	Steps to correct the noncompliance with the standard: ED corrected on site Measures to prevent the noncompliance from occurring again: HWD to review all MC charts to ensure safe/secure environment documentation is filled out completely and in each MC chart. BOM and/or HWD to utilize move in checklist to ensure all documentation is received and a tickler system will be used for updates. Person(s) responsible for implementation of each step and/or monitoring preventative measures. HWD to ensure all charts are compliant. BOM/HWD to utilize checklist and tickler system. ED will spot audit to ensure compliance
Standard #:	22VAC40-73-50-B
Description:	Based on review of resident record, the facility failed to ensure that each record contain a written disclosure which contains all of the requirements of Standard 22VAC40-73-50 and that the disclosure be signed by the resident or by his legal representative. Evidence: The Disclosure for Residents #1 and # 3 were blank of the required elements in Standard 22VAC40-73-50 and there were no resident or legal representative signatures.
Plan of Correction:	Steps to correct the noncompliance with the standard: POA/Resident contacted and Disclosure completed. Measures to prevent the noncompliance from occurring again: BOM to utilize a move in checklist to ensure disclosure is completed. BOM to complete a file audit to ensure compliance. BOM to start tickler system to ensure annual review of disclosures are also compliant. Person(s) responsible for implementation of each step and/or monitoring preventative measures BOM will utilize checklist ED and/or HWD to do final review prior to new move in. ED to perform random audit monthly to spot check.
Standard #:	22VAC40-73-260-A
Description:	Based on a review of staff records the facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days of employment. Evidence: The employee file for Staff #3 (D.O.H) 12/20/2022 did not contain evidence of the staff member having First Aid certification.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 4/25/23 and 5/11/23, the easel that contained the on-site person in charge was inaccurate.
Plan of Correction:	Steps to correct the noncompliance with the standard: LED and/or MOD to update easel board every am to show who the designated charge person is for that day. Measures to prevent the noncompliance from occurring again: LED and/or MOD to ensure compliance daily Person(s) responsible for implementation of each step and/or monitoring preventative measures. LED will be responsible for daily upkeep of easel board. ED and/or MOD to observe compliance during daily walkthrough.
Standard #:	22VAC40-73-310-H
Description:	Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals with psychotropic medications without a treatment plan. Evidence: Resident # 4 was prescribed Celexa 20mg 1 tablet daily. There was no psychotropic treatment plan in the resident file at the time of inspection.
Plan of Correction:	Steps to correct the noncompliance with the standard: Nurse contacted MD and obtained Psychotropic treatment plan. Measures to prevent the noncompliance from occurring again: HWD to train charge nurses on required treatment plans. Charge nurse to request a new/updated form with any medication changes. HWD to audit, then spot check monthly to ensure compliance. Person(s) responsible for implementation of each step and/or monitoring preventative measures.HWD set up training on 7/26/2023 with charge nurses. HWD to audit and review monthly for compliance. ED will spot check
Standard #:	22VAC40-73-380-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the personal and social information document was kept current. Evidence: 1. Resident #1?s personal and social information data form did not include the resident?s allergies. 2. Resident # 3?s personal and social information data form did not include the resident?s date of admission. 3. Resident # 4?s personal and social information data form did not include the resident?s allergies.
Plan of Correction:	Steps to correct the noncompliance with the standard: Social Data forms updated by hand to fill in any missing information. Measures to prevent the noncompliance from occurring again: ALIS face sheets to be updated with VA specific requirements. In the meantime, all social data forms will be updated on state form and kept current until the update in ALIS takes place. HWD to audit all charts to ensure compliance. BOM will ensure completion on admission by utilizing move in checklist. Person(s) responsible for implementation of each step and/or monitoring preventative measures HWD/ED to audit all charts to ensure social data sheet is completed fully. BOM to utilize move in checklist to ensure completion upon move in. ED to spot check monthly
Standard #:	22VAC40-73-410-A
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure upon admission, it would provide an orientation for new residents and their legal representatives. Evidence: 1. Resident #6 was admitted to the facility on 1/7/2023 and the resident did not receive orientation until 1/19/2023. 2. Staff #1 acknowledged the resident did not receive orientation upon admission as evident by the orientation documentation.
Plan of Correction:	Steps to correct the noncompliance with the standard: BOM to audit all files to ensure compliance Measures to prevent the noncompliance from occurring again: BOM to utilize a move in checklist to ensure orientation is completed on admission. Person(s) responsible for implementation of each step and/or monitoring preventative measures. BOM to utilize move in checklist to ensure all documentations are reviewed and complete. ED to review move in checklist and ensure compliance.
Standard #:	22VAC40-73-440-B
Description:	Based on record reviewed, the facility failed to ensure that uniform assessment instrument (UAI) forms were approved and signed by the administrator or the administrator's designee. Evidence: The UAI dated 4/14/2023 for Resident #3 and the UAI dated 1/1/2023 for Resident #4 did not contain an assessor signature and signature of the administrator or administrator designee.
Plan of Correction:	Steps to correct the noncompliance with the standard: ED corrected on site Measures to prevent the noncompliance from occurring again: HWD to review UAI with ED once completed. HWD to maintain tickler system. ED will review all UAI?s before filing. ED to review tickler monthly. Person(s) responsible for implementation of each step and/or monitoring preventative measures HWD to ensure all completed UAI?s reviewed with ED ED to review all UAI?s and review tickler system
Standard #:	22VAC40-73-450-E
Description:	Based on resident record reviewed, the facility failed to have the Individualized Service Plan (ISP) signed by the resident or his/her legal representative. Evidence: The ISP dated 1/21/2023 for Resident #1, the ISP dated 8/10/2021 for Resident # 5, and the ISP for Resident # 6 with identified need effective 1/10/2023 (ISP did not contain date of facility representative signed), did not contain resident or representative signatures.
Plan of Correction:	Steps to correct the noncompliance with the standard: HWD scheduled meetings with families and or residents to obtain signature. HWD to review with ED UAI and ISP. Measures to prevent noncompliance from occurring again: HWD to use tickler to ensure family meetings are scheduled each month when care plans are due to be updated and with change of condition. If POA is unable to be present, HWD to document that it was reviewed over phone if applicable, HWD to email care plan to POA and attach copy of email. Person(s) responsible for implementation of each step and/or monitoring preventative measures HWD to utilize tickler to ensure care plan meetings are completed timely. HWD will ensure signature is obtained or have documented as listed above. ED to review tickler each month and spot check ISP?s for compliance
Standard #:	22VAC40-73-450-F
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure individualized service plan (ISP) shall be reviewed at least every 12 months and as needed as the condition of the resident changes. Evidence: 1. Resident # 3 is receiving hospice services which are not documented on the ISP. 2. The UAI dated 1/12/2023 for Resident # 4 assesses the resident as not needing assistance in wheeling however the resident?s ISP states the resident does not perform the act as he is confined to a bed/chair and unable to ambulate.
Plan of Correction:	Steps to correct the noncompliance with the standard: Authorization for approval of Special care unit obtained from POA Measures to prevent the noncompliance from occurring again: HWD and/or BOM will utilize move in checklist to ensure documentation received and signed prior to admission to MC. MCD and HWD to audit MC files to ensure compliance Person(s) responsible for implementation of each step and/or monitoring preventative measures. BOM or designee to obtain prior to admission. MCD/HWD to review with each admission. ED to spot audit for compliance.
Standard #:	22VAC40-73-610-B
Description:	Based on observations made during the tour of the facility on 4/25/2023 and 5/11/2023, the facility failed to have the menu for the current week posted. Evidence: 1. During the time of the on-site inspection on 4/25/2023 there was no menu posted.
Plan of Correction:	Steps to correct the noncompliance with the standard: Menu posted in main dining room Measures to prevent the noncompliance from occurring again: Menu board was removed due to remodel. DSD and/or designee will ensure menus are printed and hung each week. Person(s) responsible for implementation of each step and/or monitoring preventative measures DSD to print and hang weekly ED and/or BOM to check during daily walk through
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during the tour of the building, the facility failed to have the interior and exterior of the building maintained in good repair and kept clean and free of rubbish. Evidence: 1. The interior door which leads from the dining area to the courtyard does not latch and lock. During the inspection, the inspector was able to push the door open even when the locking mechanism was engaged. 2. Staff #5 acknowledged the door was not working properly.
Plan of Correction:	Steps to correct the noncompliance with the standard: Employee contacted and copy of first aid card received. Measures to prevent the noncompliance from occurring again: HWD/BOM to utilize new hire checklist to ensure all documentation received. HWD/ED to schedule first aid certification as needed in house for renewals and new hires. HWD to utilize tickler system to ensure timelines are being met. Person(s) responsible for implementation of each step and/or monitoring preventative measures. HWD and/or ED to utilize tickler to ensure compliance of new team members and any renewals. HWD and/or BOM to utilize new hire checklist to ensure documents are obtained as applicable.
Standard #:	22VAC40-73-880-B
Description:	Based on observation, the facility failed to ensure a temperature of at least 72 degrees Fahrenheit was maintained in all areas used by residents during hours when residents are normally awake. Evidence: During the on-site inspection on 5/11/23 at 8:14 am, the room temperature in the dining area of the facility was 66 degrees.
Plan of Correction:	Steps to correct the noncompliance with the standard: Thermostat reprogrammed to 72 degrees. ESD to order locked to cover to go around the thermostat in dining room. Measures to prevent the noncompliance from occurring again: ESD and/or ED to check thermostats during daily walkthrough and spot check. Team training scheduled for 7/17/2023 Person(s) responsible for implementation of each step and/or monitoring preventative measures ESD and/or ED to check daily. Charge nurse to check thermostat each shift.
Standard #:	22VAC40-80-120-E-2
Description:	Based on observation, the center failed to post the findings of the most recent inspection of the facility. Evidence: 1. During an inspection of the facility with Staff #1 on 5/11/2023, the findings of the most recent inspection of the center were not posted. 2. Staff #1 acknowledged the most recent inspection findings were not posted.
Plan of Correction:	Steps to correct the noncompliance with the standard: State Inspection Binder put back in lobby on credenza. Measures to prevent the noncompliance from occurring again: Binders were packed up, due to remodel. Current and previous inspections kept in binder in lobby. ED to ensure that if binder needs to be moved that it will remain easily accessible and going forward could be kept in another accessible area. Person(s) responsible for implementation of each step and/or monitoring preventative measures ED and BOM to ensure binder is out during daily walk through to ensure compliance.