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: June 23, 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

Violations:

Standard #:	22VAC40-73-1110-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a resident was assessed for continued appropriateness for residence on the facility?s special care unit. Evidence: On 6/23/23, resident # 4 a resident assigned to the facility?s special care unit record was reviewed. The record did not have a current (annual) review of appropriateness for continued stay. The last assessment in the record was conducted 3-5-22. The resident?s admission to the unit was dated 7-23-18.
Plan of Correction:	The updated assessment was completed on Resident #4 and sent to resident?s daughter for signature. All residents will be assessed annually for continued appropriateness for a special care unit. A reminder will be set up to prompt the Memory Care Director when an assessment is due and the documentation will be filed in the resident?s chart. A review of charts will be completed and any missing assessment will be done.
Standard #:	22VAC40-73-50-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it prepared and provided a statement to the prospective resident and the legal representative, if any, that disclose information about the facility. Written acknowledgement of this form shall be retained in the resident?s record. Evidence: On 6/23/23, the resident records for residents #1 (2/20/23) and #3 (date of admit 6/2/22) did not have documentation a disclosure statement had been provided.
Plan of Correction:	A checklist is used with every new admission to ensure disclosure statements are signed upon admission and filed in the resident?s file. This responsibility falls on the Executive Director or designee. Resident #1 and Resident #3 signed disclosure statements on 07/06/2023. A review of all resident filed will be completed and any missing disclosure statements will be signed. Audits will be conducted for the next ten admissions.
Standard #:	22VAC40-73-210-B
Description:	Based on staff record review 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. A review of Staff # 4?s record did not contain the required number of annual training hours. 2. Staff #10 acknowledged the staff record for Staff #4 did not contain the required amount of annual training.
Plan of Correction:	An audit of employee training will be completed and the Business Office Manager will report compliance weekly to department heads. Training for all staff will be completed using in-services, and online Relias training. Individual department heads will be responsible for ensuring completion. Staff #4 is no longer employed by Dominion Village at Williamsburg.
Standard #:	22VAC40-73-250-D
Description:	Based on staff records reviewed, the facility failed to ensure each staff person member?s tuberculosis (TB) risk assessment be completed annually. Evidence: The staff records for staff members #2 and #3 did not contain TB risk assessment forms.
Plan of Correction:	Annual TB Risk Assessments are given to the nurse practitioner every January by the Business Office Manager for completion. Random file audits will be completed monthly by Executive Director. Staff #2 is scheduled to have a TB Risk Assessment done on 8/21/23 but did have a negative TB test before beginning work in January 2023. An audit of all employee files will be conducted to verify TB risk assessments are up to date.
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 #4 (D.O.H) 2/5/2022 did not contain evidence of the staff member having First Aid certification.
Plan of Correction:	First Aid certification will be completed for each direct care staff member. The Health and Wellness Director will arrange to have all staff certified by the completion date. Staff #4 is no longer employed by Dominion Village at Williamsburg. Employees will be scheduled for first aid training at orientation.
Standard #:	22VAC40-73-260-C
Description:	Based on observation and staff interviewed, the facility failed to ensure a listing of all staff who have current first aid or CPR was posted in the facility so that the information is readily available to all staff at all times. The posting should also be kept up to date. Evidence: On 6/23/23, staff # 2 was asked where the facility?s listing of staff with first aid and CPR was posted. The posted listing was not visible and was not current. Staff # 5 was listed but there was no date for the FA/CPR/AED)/ staff members #6, #7, and # were not listed and these staff members names were posted on the roster outside the med room on 6/23/23.
Plan of Correction:	An up-to-date list of all staff with current first aid and CPR certification was posted in a prominent location in the facility near the front door on July 3, 2023. It will be updated as necessary by the Business Office Manager and Health and Wellness Director.
Standard #:	22VAC40-73-310-B
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure a documented interview between the administrator or designee responsible for admission and retention, the individual, and the legal representative, if any was in the record for a resident. Evidence: Resident 1?s record did not include documentation of an interview.
Plan of Correction:	An interview between the Health and Wellness Director and the legal representative or resident will be conducted and documentation of such will be filed in the resident?s file. The retention interview was conducted on 06/30/23 for Resident #1 and documentation was filed in his chart. An audit of current charts will be completed and any documentation of interviews will be updated and an interview scheduled, if needed.
Standard #:	22VAC40-73-310-D
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure prior to admission of a resident, the facility administrator provided written assurance to the resident that the facility has the appropriate license to meet the care needs at the time of admission. Acknowledgement of this document should be signed by the resident and legal representative and kept in the resident?s record. Evidence: On 6/23/23, the records for residents #1 and # 3 did not have documentation of a signed and dated written assurance from the administrator and signed and dated by the resident and/or legal representative.
Plan of Correction:	A checklist is used with every new admission to ensure written assurances are signed by the resident or their representative and the Executive Director. Written assurances for Resident #1 and Resident #3 were signed on 7/6/23 by the residents and the Executive Director and were filed in the residents? records. An audit of all files will be completed and missing written assurances will be corrected.
Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure in accordance with 63.2-1805 D Code of Virginia, it did not admit or retain individuals with any prohibitive conditions with required documentation. Evidence: 1. On 6/23/23, resident # 7?s record documented resident administered Sertraline. The facility?s, ?Psychopharmacologic Medication Treatment Plan? form dated 3/27/23 was blank for psychotropic/ psychoactive medications. 2. Resident # 3?s record did not have documentation of psychotropic treatment plan for the following medication being administered: (a) Lorazepam, (b) Seroquel and (c) Trazadone medications noted on 6-5-23 signed physician orders.
Plan of Correction:	The Health and Wellness Director is reviewing all orders monthly to ensure all new orders for psychotropic medications have a treatment plan. Resident #7 and Resident #3 both had Psychotropic Medication Treatment Plans completed by Meredith Leary, FNP on 08/16/23. An audit of resident psychotropic medication will be completed and verified that a treatment plan is in place when required.
Standard #:	22VAC40-73-320-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure within 30 days preceding admission, a person shall have a physical examination by an independent physician. Evidence: On 6/23/23, resident #3 did not have a physical examination prior to being admitted. The resident?s admit date noted as 6/2/22.
Plan of Correction:	All new admissions, including transfers from other facilities, will be treated as new admissions including having pre-admission physical completed and documented. This item is included on the new admission checklist and the Health and Wellness Director will ensure its completion and accuracy. An audit of all charts will be completed to verify physical examination has been completed and documented in the resident?s chart.
Standard #:	22VAC40-73-350-B
Description:	Based on record review, the facility failed to ascertain, prior to each resident?s admission whether a potential resident is a registered sex offender. Evidence: The resident record for resident #1 did not contain a Sex Offender Screening.
Plan of Correction:	Results of a search on the sex offender database are printed and filed in the resident?s file. This responsibility is with the Business Office Manager and will be part of the monthly file audits. A search was conducted on Resident #1 on 07/26/23, a screenshot printed, and the documentation filed in the resident?s file. An audit of all resident files will be completed and any missing sex offender information will be added.
Standard #:	22VAC40-73-390-A
Description:	Based upon documentation review, the facility failed to ensure at or prior to the time of admission, there shall be a written agreement signed by the resident. Evidence: Resident #1 was admitted to the facility on 2/20/23 and there was no signed resident agreement in the file presented to the licensing inspection at the time of the inspection.
Plan of Correction:	All residents, including those who share a room with a spouse, will have their own resident agreement on file. A separate agreement for Resident #1 was signed on 08/16/2023 effective 2/20/23. The Executive Director does all lease signings and will ensure compliance. An audit of current resident files will be completed to verify signed resident agreements.
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: Resident #1 was admitted to the facility on 2/20/2023. There was no documented evidence in the resident record of the resident being provided an orientation to the facility.
Plan of Correction:	The orientation checklist is being used to ensure residents are given an orientation to the facility. An orientation checklist for Resident #1 was completed on . This responsibility will be carried out by the Executive Director or designee. An audit will be done to verify orientation was completed and any missing documentation will be completed.
Standard #:	22VAC40-73-440-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure annual assessment and reassessment due to significant change in the resident?s condition, using the Uniform Assessment Instrument (UAI), shall be utilized to determine whether a resident?s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: On 6/23/23, resident #4?s, record did not have documentation of an updated UAI. The UAI in the record was dated 7/23/2020 and 7/23/2021. The resident?s date of admit noted as 7/23/2018.
Plan of Correction:	The UAI for Resident #4 was updated and a copy sent to the POA for signature. All residents will have their UAIs updated annually or upon a significant change in condition. A reminder will be set up to prompt the Health and Wellness Director or Memory Care Director when an assessment is due. An audit will be conducted to verify residents with a significant change in condition will have an updated, signed UAI.
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. On 6/23/23, resident #7?s individualized service plan (ISP) dated 6/5/23 did not include resident?s fluid restriction. Resident returned from hospital stay 4/28/23 to 5/3/23, order for fluid restriction 34-48- ounces of fluid a day. The resident is allergic to coconut and nuts, these items not noted on the ISP. The ISP noted mechanical help for bathing but did not identify the mechanical device. The record included signed orders for eye-drops and creams to be kept at bedside, this information was not on the ISP. The UAI and ISP documented all medication to be administered by layperson and nurse. Resident physical therapy services not on the ISP, services 5/6/23 and discharged 6/1/23. 2. Resident #2?s, UAI (dated 1/23/23 noted bathing need assessed as mechanical help/supervision. The ISP signed 5/3/23 noted ?staff will assist resident with washing entire body including arms, legs, back, hair, feet and perineum?. 3. Resident # 4?s record did not have documentation of a current ISP. The ISP in the record was signed 3/31/22. The resident?s date of admit noted as 7/23/18.
Plan of Correction:	1. In the future, it will be detailed on the ISP that the resident is responsible for monitoring their fluid intake and following the physician orders for fluid restriction. Home Health will educate and verify understanding and document it on the ISP as such. All other violations corrected on the ISP. 2. The UAI of Resident #2 was corrected. 3. Resident #4?s ISP was completed and sent to the POA for signature. All ISPs will be updated upon significant changes to residents? condition.
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. The June 2023 MAR for resident #7 did not include a diagnosis, condition, or specific indications for administering the following prescribed medications: Metoprolol Succ ER 25 mg, Preservision Areds 2 230-5 mg, Spironolactone 25 mg, Warfarin Sodium 5 mg, Warfarin Sodium 6 mg, and Ocusoft LID Scrub Plus. 2. The June 2023 MAR for resident #2 did not include a diagnosis, condition, or specific indications for administering the following prescribed medications: Albuterol Sulfate, Lisinopril 2.5 mg, Lorazepam 1 mg, and Amlodipine Besylate 2.5 mg. 3. The June 2023 MAR for resident #3 did not include a diagnosis, condition, or specific indications for administering the following prescribed medications: Austedo 9 mg, Carb-Levo ER50 mg- 200 mg, Furosemide 20 mg, Memantine HCL F/C 5 mg, and Potassium Chloride 10 meq.
Plan of Correction:	FNP completed the missing information for Residents #7, #3, and #2. The Health and Wellness Director will ensure all orders have diagnoses and dosage instructions going forward and the accuracy of the MAR will be confirmed.
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the first aid kits were checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. Evidence: On 6/23/23 during a check of the facility?s first aid kits, the first aid in the AL medication room were missing the following items: (a) disposable CPR mask; (b) cold pack; (c) assorted roller gauze; (d) hand cleaner/antiseptic towelette; (e) plastic bags; (f) scissors; (g) flashlight/extra batteries; (h) thermometer and (i) triangular bandages, Tylenol expired 5-2022. The first aid kit on the vehicle were missing the following items: (a) disposable CPR masks; (b) disposable waterproof gloves; (c) no extra batteries and (d) no first aid/CPR manual. The first aid kits did not contain a checklist.
Plan of Correction:	All missing items have been ordered and will be distributed among the five first aid kits. A checklist is being utilized to ensure all items are present in all first aid kits. The kits will be examined monthly using this checklist. The Environmental Services Director will carry out this responsibility.