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 7, 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 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 6/7/2024 9:00 am -1:30 pm 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: 36 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: 4 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 3 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. 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 #:	22VAC40-73-250-C
Description:	Based on a review of staff records, the facility failed to verify that each staff person has received a copy of his or her current job description. Evidence: Staff member #3?s (D.O.H. 12/16/2023) file contained a job description which was signed on the date of the inspection, 6/7/2024.
Plan of Correction:	Steps to correct the noncompliance with the standard: Job descriptions to be signed on hire and annually Measures to prevent the noncompliance from occurring again: BOM will use orientation checklist to ensure everything is completed timely Person(s) responsible for implementation of each step and/or monitoring preventative measures BOM to audit all files, job descriptions that are signed online will be printed and put in file. Any missing will be reported to ED. ED will review at least quarterly
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: On the date of the inspection 6/7/2024, the posting of the on-site person in charge was not accurately updated to reflect the person who was in charge of the building at the time the inspector entered the building. The welcome board reflected the date as being June 5, 2024.
Plan of Correction:	Steps to correct the noncompliance with the standard: LED/charge nurse to make sure daily posting board is current with date and team members Measures to prevent the noncompliance from occurring again: Nurse on Duty/LED or designee to update board daily as part of the daily routine Person(s) responsible for implementation of each step and/or monitoring preventative measures LED or designee to ensure board is completed daily as part of daily management rounds. ED to spot check
Standard #:	22VAC40-73-350-B
Description:	Based on review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. Evidence: Resident # 3 had an admission date of 3/17/2024 and the Sex Offender Screening was conducted on 3/19/2024.
Plan of Correction:	Steps to correct the noncompliance with the standard: Sex offender screening to be done prior to admission Measures to prevent the noncompliance from occurring again: BOM or designee to utilize move-in checklist and ensure completed prior to admission Person(s) responsible for implementation of each step and/or monitoring preventative measures BOM or designee to conduct an audit of all resident files to ensure all resident files have completed sex offender screening. BOM or Designee to utilize move- in checklist. Any resident files missing sex offender screening will be reported to ED. ED to review move-in checklist with all new move ins and quarterly.
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review and interview with staff, the facility failed to have the ISP signed and dated by the licensee, administrator, or designee and by the resident or his legal representative. Evidence: 1. Resident #1 has an ISP dated 2/11/2024. There were no signatures on the ISP of the resident or his legal representative. 2. Resident #2 has an ISP not dated 9/28/2023. There were no signatures on the ISP of the resident or his legal representative. 3. Resident #3 has an ISP dated 4/15/2023. There was no signature on the ISP of the resident or his legal representative. 4. Resident #4 has an ISP dated 8/23/2024. There was no signature on the ISP of the resident or his legal representative.
Plan of Correction:	Steps to correct the noncompliance with the standard: HWD/ED to schedule care meetings monthly/as needed to ensure signatures obtained timely Measures to prevent the noncompliance from occurring again: HWD/ED to conduct audit of all resident files to ensure all ISPs have required signatures. HWD or designee will review care plans and set up family meetings. HWD/ED to utilize tickler system Person(s) responsible for implementation of each step and/or monitoring preventative measures HWD or designee to review weekly. ED to review at least quarterly to ensure completion
Standard #:	22VAC40-73-550-G
Description:	Based on the review of facility records and staff interviews conducted the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities are reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person. Evidence: 1. The file presented to the Licensing Inspector at the time of inspection for Resident #1 contained a review of resident?s rights dated 1/19/2023. 2. The file presented to the Licensing Inspector at the time of inspection for Resident #2 contained a review of resident?s rights dated 5/16/2019. 3. The file presented to the Licensing Inspector at the time of inspection for Resident # 4 did not contain a signed copy of the resident?s rights.
Plan of Correction:	Steps to correct the noncompliance with the standard: Resident rights to be reviewed on move-in and annually Measures to prevent the noncompliance from occurring again: BOM or designee will conduct audit all resident files to ensure all residents have Resident Rights signed. Any missing will be reported to ED. BOM or designee will utilize move- in checklist to ensure completion on move in. BOM or designee will utilize tickler to ensure signature is obtained for each resident/POA annually. ED will review at least quarterly Person(s) responsible for implementation of each step and/or monitoring preventative measures BOM or designee to audit files to ensure completion. BOM or designee will utilize move in checklist on move in and use a tickler to ensure annual completion
Standard #:	22VAC40-73-640-A
Description:	Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes. Evidence: 1. A review of the Narcotic Inventory Verification Form for the memory care and Assisted Living documented staff failed to ensure counts of all controlled substances occurred between oncoming staff and off going staff. 2. Staff members #1 and #2 acknowledged the forms did not document narcotic medication counts were conducted during the change of each shift.
Plan of Correction:	Steps to correct the noncompliance with the standard: Training set up with nurses on total narc count forms. All med techs will be in-services on Narcotic medication policy to include counting at start and end of each shift. Measures to prevent the noncompliance from occurring again: HWD/ED or designee to review narc forms weekly to ensure forms are completed entirely. Any blanks will be reported to ED. Person(s) responsible for implementation of each step and/or monitoring preventative measures Charge nurses or designee to ensure to sign total count form. HWD or designee to review weekly to ensure compliance. ED will review at least quarterly
Standard #:	22VAC40-73-640-D
Description:	Based on observation and staff interviewed, the facility failed to ensure the pharmacy reference book, drug guide, or medication handbook was no more than two years old as reference for staff who administer medications. Evidence: 1. The pharmacy drug guide on-site on 6/7/2024 was dated 2021. 2. Staff #2 acknowledged the pharmacy reference book was not dated within the past two years.
Plan of Correction:	Steps to correct the noncompliance with the standard: 2024 Drug book ordered and will be placed on medication cart. Measures to prevent the noncompliance from occurring again: HWD or designee to review monthly during med cart audit to ensure current book is on med cart. Any missing drug book will be reported to ED. Person(s) responsible for implementation of each step and/or monitoring preventative measures HWD/ED to check monthly. ED will review med cart audits at least quarterly.
Standard #:	22VAC40-73-940-A
Description:	Based on the record review the facility failed to ensure an assisted living facility shall comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determine by at least an annual inspection by the appropriate fire official. Evidence: 1. The facility?s record contains an annual fire inspection completed on 5/5/2023. 2. Staff # 4 acknowledged the facility?s record of the last fire inspection completed is dated 05/5/2023.
Plan of Correction:	Steps to correct the noncompliance with the standard: Began calling for annual fire inspection the end of April as we knew we were due in May. At this time inspection not completed, but we will continue to call Measures to prevent the noncompliance from occurring again: ESD or designee will begin calling for inspection 2 months prior to being due. ESD or designee will continue to call and schedule until completion Person(s) responsible for implementation of each step and/or monitoring preventative measures ESD to ensure fire inspection is scheduled annually and as needed. ED will review at least quarterly for compliance
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: 1. On 6/7/2024 during the inspection of the First-Aid kit for the building, the hand sanitizer had an expiration date of 9/1/2023. The First-Aid kit for the van contained hand sanitizer with an expiration date of 9/1/2023 and antibiotic alcohol pads with an expiration date of 4/2023. 2. Staff members #1 and #4 both acknowledged the above-mentioned items were expired.
Plan of Correction:	Steps to correct the noncompliance with the standard: Items replaced on site in first aid kit. Measures to prevent the noncompliance from occurring again: Night nurse or designee to utilize checklist to check first aid weekly and replace items as needed LED/MCD or designee will utilize checklist to check first aid kit on bus weekly and replace items as needed. Any items missing or expired will be reported to ED. Person(s) responsible for implementation of each step and/or monitoring preventative measures Night nurse, MCD/LED or designee to complete checklist weekly. ED will review at least quarterly