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 27, 2024

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: 5/29/2024 9:39am-3:10 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can 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 #:	22VAC40-73-1110-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:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records the facility failed to ensure that each staff person submit the results of a tuberculosis (TB) risk assessment on or within seven days prior to the first day of work at the facility and that each staff person submit the results of a risk assessment annually. Evidence: 1. The file for Staff #2 (D.O.H. 2/27/2024) did not contain a valid TB risk assessment as the assessment form was not completed by a licensed healthcare provider. The form only had the staff member?s signature. 2. The file for Staff #3 (D.O.H. 2/8/2019) did not contain a current TB risk assessment. The most recent TB risk assessment form was dated 2/20/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review and staff interview, the facility failed to ensure that the Uniform Assessment Instrument (UAI) is completed as required by 22VAC30-110 with the assessment, including functional status. Evidence: Bathing on the UAI for Resident #3 states the resident needs assistance in bathing but does not indicate the type of assistance the resident needs, that section was blank. The Individualized Service Plan states the resident needs mechanical and human supervision for bathing.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on staff interview and review of resident records, the facility failed to update the Individualized Service Plan (ISP) at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: The Uniform Assessment Instrument (UAI) for Resident #3 states the resident needs mechanical and human help with toileting however the ISP states the resident only requires mechanical help.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-580-A
Description:	Based on record review, the facility failed to ensure when any portion of an assisted living facility is subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulations, as evidenced by an initial and subsequent annual reports from the Virginia Department of Health. Evidence: 1. During the on-site inspection the most recent documented health inspection was 1/5/2023. 2. Staff #1 acknowledged the facility?s health inspection was not current.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation and staff interview, the facility failed to ensure that all medications and dietary supplements were stored in a manner consistent with the current standards of practice. Evidence: 1. During the on-site inspection on 5/29/2024, Licensing Inspectors observed the door to the medication door being unlocked. Inside the medication room, there were 5 gray bins filled with medication unsecured in the corner of the room. 2. Staff #3 acknowledged the door to the medication room was not locked and the bins contained medication which was unsecured.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-970-A
Description:	Based on document review and staff interviewed the facility failed to ensure fire and emergency drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills requested for each shift in a quarter shall not be conducted in the same month. Evidence: 1. On 05/29/2024, the facility provided evidence of fire and emergency evacuation drills for first shift and for second shift. There was no evidence of the facility conducting fire and emergency evacuation drills for the first shift for the first quarter of 2024. 2. Staff # 1 acknowledged the facility did not have documentation of a fire and emergency evacuation drill being conducted for the first shift for the first quarter of 2024.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-80-120-E-1
Description:	Based on observations made during the tour of the building, the facility failed to ensure certain documents related to the terms of the license are posted as required on the premises of the facility, including the most recently issued license. Evidence: 1. During the on-site inspection 5/29/2024 there was no facility license posted in the facility for the licensing inspector to inspect. 2. Staff #1 acknowledged the license was no posted.
Plan of Correction:	Not available online. Contact Inspector for more information.