Dominion Village at Poquoson
Families consistently rate this highly — reviewers highlight compassionate and attentive nursing staff. Schedule a visit to confirm the fit.
based on 56 Google reviews
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What this means for your family
This facility is an excellent choice if you prioritize a warm, family-like environment and high-quality dining. While the nursing staff is highly praised for their compassion, you should specifically inquire about staffing levels and protocols for timely hygiene care to ensure your loved one's needs are met promptly.
Google Reviews
Google Reviews
56 reviews analyzed“Dominion Village at Poquoson is highly regarded by families for its compassionate, family-like atmosphere and attentive nursing staff that provides personalized care. While the facility is praised for its cleanliness and high-quality dining, some reviewers have noted concerns regarding staffing levels and specific instances of delayed resident care.”
Quality Themes
Tap a score for detailsStrengths
- Compassionate and attentive nursing staff
- Clean and well-maintained environment
- High-quality, delicious dining options
- Warm, family-oriented community atmosphere
Concerns
- Need for increased staffing levels (mentioned by 2 reviewers)
- Instances of delayed hygiene or care
Rating Trends
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Distribution
How They Respond to Reviews
This facility actively engages with reviewer feedback.
Questions for Your Tour
- 1We've heard wonderful things about the dining experience here; could you tell us more about the menu and how much input residents have in meal choices?
- 2The community seems to have such a warm, family-oriented atmosphere; how do you foster that sense of connection among the 43 residents?
- 3With the specialized memory care certification, what specific routines or sensory activities are in place to engage residents throughout the day?
- 4We noticed how much care you put into responding to community feedback; how does the management team use resident or family input to improve daily care routines?
- 5In terms of medical support, how is the nursing staff structured to ensure consistent, timely assistance with personal care and hygiene, especially during busier shifts?
- 6What is the protocol for handling medical emergencies or sudden changes in health status during the overnight hours?
Personalized based on this facility's data
Key Review Excerpts
“My mother would not be alive if it wasn’t for the watchful and compassionate staff at Dominion Village at Poquoson. She had a stroke. You only have 2 hours to treat a stroke. The staff found her within an hour and called 911.”
“The food was another highlight! It was not only delicious but beautifully presented—just like something you’d expect at a family dinner at home.”
“When you come in and your mother is still in bed at noon with her lunch laying on her chest, it’s not a good thing. Then being told they will clean her up after dinner is not acceptable.”
State Inspection History
State Inspections
Source: VA State Licensing Agency
May 7, 2025Routine11Report
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: 5/7/2025 (8:22 am- 2:15 pm), 5/8/2025 7:37 am- 8:35 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: 22 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 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
Based on records 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 without required documentation. Evidence: 1. Resident # 7?s medication administration record document the resident was prescribed Lexapro 5 mg. There was no psychotropic treatment plan in the resident?s file for the medication. 2. Staff #1 acknowledged there was no psychotropic treatment plan in the resident record for the medication.
Based on records reviewed, the facility failed to ensure that a fall risk assessment was reviewed and updated after every fall. Evidence: 1. Resident # 3 had documented falls on 9/3/2024, 9/5/2024, 10/15/2024, 10/20/2024, 10/22/2024, 11/6/2024, 12/23/2024, and 4/15/2025. There were no corresponding fall risk assessments in the resident file for the falls. 2. Staff # 4 acknowledged there were no fall risk assessments in the resident file for the above-mentioned falls.
Based on record review and interview with staff, the facility failed to ensure individualized service plans ( ISP
Based on resident record review the facility failed to have the ISP
Based on observations made during a tour of the building, the facility failed to ensure the current month's activity schedule shall be posted in a conspicuous location in the facility. Evidence: 1. During the on-site inspection on 5/8/2025, there was no posted activities calendar in the memory care unit. The activity calendar on the monitor in the assisted living portion of the building displayed an activity calendar for April 2025. 2. Staff #1 acknowledged the current activities calendar was not posted.
Based on observation the facility failed to ensure that the rights and responsibilities of residents shall be printed in at least 14-point type and posted conspicuously in a public place. Evidence: 1. During a tour of the facility on 5/7/2025, the licensing inspector observed that the Rights and Responsibilities of Residents were not posted. 2. Staff # 1 acknowledged the Resident Rights and Responsibilities were not posted.
Based on observation and interview, facility failed to ensure menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents and any substitutions or additions shall be recorded on the posted menu. Evidence: 1. During the inspection of the facility with Staff #1 on 5/7/2025, there was no menu posted on the memory care unit. 2. Staff # 1 acknowledged the menu was not posted.
Based on a review of resident records the facility failed to include all required information on the medication administration record ( MAR
Based on resident review and review of the Medication Administration Record ( MAR
Based on observation and staff interviewed, the facility failed to ensure the hot water taps available to residents shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F. Evidence: 1. During an inspection of the facility on 5/8/2025, the hot water temperature in the bathroom shared between resident rooms 18 B and 17 B measured 125.7 F, the bathroom shared between resident rooms 16 B and 15 B measured 129.5 F, and the bathroom shared between resident rooms 4 A and 3 A measured 122.2 F. 2. Staff # 2 acknowledged the readings for the hot water temperatures.
Based on record review, the facility failed to ensure there is a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal. Evidence: 1. During the facility inspection with Staff # 1, the Licensing Inspector pulled the call bell in the bathroom for resident room 19 B. The call bell did not work. 2. The Licensing Inspector pulled the call bell in the shared bathroom for resident room 16 B. The call bell in the bathroom did not work. 3. The Licensing Inspector looked for the call bell in the bedroom for resident room 16 B. The call bell was missing. 4. The Licensing Inspector pulled the call bell for the bathroom for resident room 14 B. The call bell did not work. 5. The Licensing Inspector looked for the call bell in the bedroom for resident room 10 A. The call bell was missing. 6. The Licensing Inspector pulled the call bell in the shared bathroom for resident room 10 A. The call bell in the bathroom did not work. 7. Staff # 1 acknowledged all the above instances regarding the missing or nonworking call bells.
Jun 7, 2024Routine
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
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.
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.
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.
Based on resident record review and interview with staff, the facility failed to have the ISP
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.
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.
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.
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.
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.
Jun 7, 2024Other
Type of inspection: Other Self-Report Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/7/2024 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 4/23/2024 regarding allegations in the area(s) of: Resident Care and Related Services 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: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. 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
Based on facility self-report, staff interview and a review of resident records, the facility failed to provide supervision of resident schedules, care and activities. Evidence: 1. The facility provided a self-report on 4/23/2024 which stated Resident #1 (who resides on the safe, secure, unit) was observed walking out of another resident?s room holding a cleaning chemical. Resident #1?s shirt was reportedly wet, and she stated she drank some of the fluid. Resident was sent to the Emergency Room for evaluation. 2. Resident #1?s Individualized Serve Plan dated 4/15/2024 stated the resident is disoriented to some spheres all of the time and that staff reorient the resident to time and place as needed. 3. Both Staff #1 and #2 acknowledge the incident occurred.
Jan 10, 2024Complaint
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: Staffing 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: 0 Number of staff records reviewed: 17 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 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
Based on the employee timesheets reviewed, the facility failed to ensure that when 20 or fewer residents are present in the safe secure unit that at least two direct care staff members were awake and on duty at all times in the special care unit. Evidence: The staff schedule and employee timesheets provided by Staff #1 to licensing inspector for 1/1/2024 documented the facility?s safe, secure, unit had one staff member working from 7am- 3 pm shift.
Jan 10, 2024Complaint
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
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.
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.
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.
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.
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.
Apr 25, 2023Routine15Report
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
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.
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.
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.
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.
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.
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.
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.
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.
Based on record reviewed, the facility failed to ensure that uniform assessment instrument ( UAI
Based on resident record reviewed, the facility failed to have the Individualized Service Plan ( ISP
Based on records reviewed and staff interviewed, the facility failed to ensure individualized service plan ( ISP
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.
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.
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.
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.
Apr 25, 2023Complaint
Type of inspection: Other/self-report/complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/25/2023 8:19am- 4:14pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 3/1/2023 regarding allegations in the area(s) of: Resident Care and Related Services An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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
Based on documentation and record review, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises. Evidence: 1. On 3/1/2023 at 4:40pm two residents of the safe, secure, environment were able to walk out of the facility and walk down the road to the neighborhood behind the facility. 2. Staff #1 acknowledged the residents eloped from the facility through a side exit during renovations of the unit.
Jun 13, 2022Routine
Type of inspection: Renewal Date(s) of inspection the licensing inspector was on-site at the facility for each day of the inspection: 6/13/22 & 6/17/22 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: 30 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 7 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing Inspectors observed activities, meals and medication passes during the inspection. Additional Comments/Discussion: n/a 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.
Based on observation and interview with staff, the facility failed to ensure certain documents related to the terms of the license were posted on the premises of the licensed facility, including the most recently issued findings of the most recent inspection of the facility. Evidence: During the on-site inspection on 6/13/22, the most recent findings from the inspection dated 5/17/21 were not posted.
Based on staff interview and observation the facility failed to have a listing of all staff who have current certification in First Aid and CPR posted in the facility readily available to staff. Evidence: During the on-site inspection on 6/13/22, there was not a posting of staff members who had current certification in First Aid and CPR.
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 6/13/22, the easel that contained the on-site person in charge was blank. Later during the inspection, the LI observed Staff # 7 updating the easel.
Based on observations made during the on-site inspection on 6/17/22, the facility failed to document the menu substitutions on the posted menu. Evidence: During the on-site inspection on 6/17/22, the posted menu listed green salad, battered fried fish or roast beef, onion roasted potatoes, Normandy blend, baked roll. Meat balls, spinach, macaroni and cheese, and a roll were observed on each resident?s plate. The change was not made on the posted menu.
Based on observations made during the inspection of the facility, the facility failed to have the menu for the current week posted. Evidence: 1. During the on-site inspection on 6/13/22, there was no posted menu in a place conspicuous to residents. 2. Staff # 8 acknowledged there was no weekly menu posted.
Based on documentation review, the facility failed to include all required documentation on the Medication Administration Record ( MAR
Based on observation and interview, the facility failed to maintain the interior and exterior of the building in good repair. Evidence: During a tour of the facility on 6/13/22, the following areas were observed to be in need of repair: 1. There were exposed wires from an alarm system in the main hallway on the memory care unit. 2. The vinyl floor was peeling in a bedroom on the memory care unit. 3. Staff # 8 acknowledged items listed above were in need of repair.
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