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 27, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/10/2024 10:25 am -3:19 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1/2/2024 regarding allegations in the area(s) of: Resident Care and Related Services Buildings and Grounds The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Additional Comments/Discussion: All resident records were not available for licensing inspectors to review during the inspection. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the (allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the (complaint(s) 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 #:	22VAC40-73-1180-A
Complaint related:	Yes
Description:	Based on observation and staff interview, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision. Evidence: 1. During a inspection of the memory care unit, Licensing Inspectors observed Spic and Span by the kitchen sink unattended in an open area accessible to the residents. 2. During the inspection of the resident rooms in the memory care unit, Licensing Inspectors observed personal hygiene items (shampoo, lotion, razors, wound cleaner, tooth paste, cologne, perineum wash, hand sanitizer, body spray, barrier ointment, cleaning foam, deodorant, shaving cream, and mouthwash), unattended in the resident rooms (19-A, 18-A, 16-A, 15-A, 14-A, 13-A, 12-A, 9-A, 8-A, 10-A). 3. The outside courtyard fencing has sharp nails that are exposed. 4. Licensing Inspector observed a metal garden trowel accessible to residents.
Plan of Correction:	Steps to correct the noncompliance with the standard: All rooms checked, any cleaning items were removed, personal care items placed in lock box under sinks in each bathroom. Meeting held with family members about safety and Memory care Fencing replaced with 8? vinyl fencing Measures to prevent the noncompliance from occurring again: Weekly checks of rooms by MCD. ED to spot check. Care staff to monitor and report any problems to MCD Person(s) responsible for implementation of each step and/or monitoring preventative measures MCD to check weekly, ED to spot check. BOM/ED to review with families prior to move in and as needed. MCD/ESD to check courtyard weekly
Standard #:	22VAC40-73-390-A
Complaint related:	No
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 or legal representative. Evidence: Resident #2?s record provided to Licensing Inspector at the time of inspection, did not contain a signed resident agreement.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-560-F
Complaint related:	No
Description:	Based upon, the staff interviews and contact, the facility failed to ensure that all records shall be made available for inspection by the department's representative. Evidence: 1. During the January 10, 2024, complaint visit, the facility failed to have the resident and staff records available for inspection by the department?s representative. 2. Staff #2 stated Resident records were locked in the former Health and Wellness Director?s office and there was no spare key available.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-A
Complaint related:	Yes
Description:	Based on observation and staff interviewed, the facility failed to ensure the interior of the building was maintained in good repair and kept clean and free of rubbish. Evidence: 1. On 1/10/2024 during a tour of the facility, various resident?s rooms were observed with large areas of vinyl flooring which was peeling and in disrepair (19-A, 14-A, 17-B). 2. The threshold is missing the transition strip from the bedroom to the shared bathroom (17A). 3. The bathroom vent was hanging shared bathroom for room 16 A. 4. The bathroom shower curtain had brown stains, shared bathroom for room 16 A. 5. The supply closet in memory care unit had mold along the floorboard. 6. Resident rooms were dusty, including ceiling fans, windowsills, and furniture. 7. The walls in the resident bathrooms walls had holes. 8. The walls in several resident bathrooms had a brown substance near the toilets and the toilet plunger. 9. The vent registers in multiple resident bathrooms were rusty. 10. The bathroom vanity floor had water damage and are peeling and deteriorating. 11. Carpet was stained 11-A. 12. The hallway door (near rooms 5B and 4B) which leads to the outside has a gap and cold air was coming through. There was a towel stuffed in the gap. 13. Dead roaches were observed under the bathroom vanity (shared bathroom for room 17-A) 14. The resident rooms were observed to have dusty ceiling fans 19-A 15. Multiple resident bedroom and bathrooms had lightbulbs that were burned out. 16. The kitchen cabinets in the memory care unit are in disrepair, there is a wooden board supporting the upper-level cabinets, the locking mechanism on the cabinets and drawers do not work therefore the residents have access to potentially harmful items such as cleaning supplies and nutritional supplement.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-B
Complaint related:	No
Description:	Based on smell and staff interviewed, the facility failed to ensure the building was well-ventilated and free from foul, stale, and musty odors. Evidence: On 1/10/2024 during a tour of the facility, the room 11A had a strong smell of urine.
Plan of Correction:	Not available online. Contact Inspector for more information.