Inspection Reports for Dominion Village at Poquoson
531 Wythe Creek Road, VA, 23662
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% worse than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
22 residents
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 22
Deficiencies: 11
May 7, 2025
Visit Reason
The inspection was a renewal inspection conducted on May 7 and May 8, 2025, to assess compliance with applicable standards and laws for the assisted living facility Dominion Village at Poquoson.
Findings
The inspection identified multiple violations including failure to maintain required documentation for psychotropic medications, incomplete fall risk assessments after falls, outdated individualized service plans (ISPs), missing signatures on ISPs, lack of posted activity schedules and menus, incomplete medication administration records, unsafe hot water temperatures, and nonfunctional call bell systems.
Deficiencies (11)
| Description |
|---|
| Facility failed to ensure psychotropic treatment plans were in resident files as required. |
| Fall risk assessments were not reviewed and updated after every resident fall. |
| Individualized service plans (ISPs) were not reviewed and updated at least annually or as needed for significant changes. |
| ISPs lacked required signatures from licensee, administrator, or resident/legal representative. |
| Current month's activity schedule was not posted in a conspicuous location in the facility. |
| Rights and responsibilities of residents were not posted conspicuously in the facility. |
| Menus for meals and snacks were not posted or dated in the memory care unit. |
| Medication administration records (MAR) failed to document effectiveness of PRN medications. |
| MARs lacked required information including diagnosis, drug strength, dosage, and indications for medications and supplements. |
| Hot water taps exceeded the required temperature range of 105 to 120 degrees Fahrenheit. |
| Call bell system was not functional or missing in multiple resident rooms and bathrooms. |
Report Facts
Number of residents present: 22
Number of resident records reviewed: 7
Number of staff records reviewed: 4
Number of resident interviews: 3
Number of staff interviews: 2
Resident #3 falls documented: 8
Hot water temperature readings (Fahrenheit): 125.7
Hot water temperature readings (Fahrenheit): 129.5
Hot water temperature readings (Fahrenheit): 122.2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Named as the current inspector conducting the inspection |
| Resident Care Coordinator | RCC | Responsible for audits, training, and corrective actions related to resident care and documentation |
| Health and Wellness Director | HWD | Responsible for audits, training, and oversight of compliance with care standards |
| Executive Director | ED | Responsible for spot checks, oversight, and ensuring compliance with corrective actions |
| Life Enrichment Director | LED | Responsible for posting activity schedules and monitoring resident rights postings |
| Dining Services Director | DSD | Responsible for posting menus and ensuring they are current |
| Environmental Services Director | ESD | Responsible for water temperature monitoring, call bell system maintenance, and related training |
Inspection Report
Renewal
Census: 36
Deficiencies: 9
Jun 7, 2024
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations related to staff records, posting of the person in charge, resident admission procedures, incomplete signatures on Individual Service Plans (ISPs), failure to review resident rights annually, medication management deficiencies, outdated pharmacy reference materials, fire inspection scheduling, and expired first aid kit items.
Deficiencies (9)
| Description |
|---|
| Failed to verify that each staff person has received a copy of his or her current job description. |
| Failed to ensure the posting of the name of the current on-site person in charge was accurate. |
| Failed to ascertain prior to admission whether a potential resident is a registered sex offender. |
| Failed to have the ISP signed and dated by the licensee, administrator, or designee and by the resident or legal representative. |
| Failed to ensure that the rights and responsibilities of residents are reviewed annually with each resident or legal representative and each staff person. |
| Failed to implement written plan for medication management ensuring accurate counts of controlled substances during staff changes. |
| Failed to ensure the pharmacy reference book, drug guide, or medication handbook was no more than two years old. |
| Failed to comply with the Virginia Statewide Fire Prevention Code by not having an annual fire inspection completed on time. |
| Failed to ensure first aid kits were checked at least monthly and contained no expired items. |
Report Facts
Number of residents present: 36
Number of resident records reviewed: 6
Number of staff records reviewed: 4
Number of resident interviews conducted: 3
Number of staff interviews conducted: 3
Date of last fire inspection: May 5, 2023
Inspection Report
Census: 36
Deficiencies: 1
Jun 7, 2024
Visit Reason
The inspection was conducted as an Other Self-Report following a self-reported incident received by VDSS Division of Licensing on 2024-04-23 regarding allegations in Resident Care and Related Services.
Findings
The investigation did not support the self-report of non-compliance; however, a violation unrelated to the self-report was identified involving failure to provide supervision of resident schedules, care, and activities. The facility submitted a plan of correction to address the cited violation.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide supervision of resident schedules, care and activities as evidenced by Resident #1 walking out of another resident's room holding a cleaning chemical and ingesting some of the fluid, requiring emergency room evaluation. |
Report Facts
Number of residents present: 36
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
Inspection Report
Complaint Investigation
Deficiencies: 5
Jan 10, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2024-01-02 regarding allegations in the areas of Resident Care and Related Services and Buildings and Grounds.
Findings
The investigation found multiple violations including unsafe access to harmful materials in the memory care unit, missing signed resident agreements, unavailable resident and staff records, and poor maintenance and cleanliness of the facility including peeling flooring, mold, rusty vents, and foul odors.
Complaint Details
The complaint was substantiated as evidence supported allegations of non-compliance with standards and violations were issued.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure harmful materials were inaccessible to residents except under staff supervision, including cleaning supplies and personal hygiene items accessible in memory care unit. |
| Resident #2's record did not contain a signed resident agreement at or prior to admission. |
| Facility failed to have resident and staff records available for inspection; records were locked with no spare key. |
| Facility interior was not maintained in good repair and was not clean or free of rubbish, including peeling vinyl flooring, missing transition strips, mold, dusty rooms, holes in walls, rusty vent registers, water damage, stained carpet, gaps in doors, dead roaches, and nonworking cabinet locks. |
| Facility failed to ensure building was well-ventilated and free from foul, stale, and musty odors; strong smell of urine observed in room 11A. |
Report Facts
Resident records reviewed: 4
Staff records reviewed: 0
Resident interviews conducted: 2
Staff interviews conducted: 4
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Jan 10, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2024-01-02 regarding staffing issues at the facility.
Findings
The investigation found non-compliance with staffing standards, specifically that the facility failed to ensure at least two direct care staff members were awake and on duty at all times in the special care unit when 20 or fewer residents were present.
Complaint Details
Complaint related: Yes. The complaint was regarding staffing issues. The evidence supported the allegation of non-compliance with staffing standards.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that when 20 or fewer residents are present in the safe secure unit, at least two direct care staff members were awake and on duty at all times in the special care unit. |
Report Facts
Number of residents present: 36
Number of staff records reviewed: 17
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 25, 2023
Visit Reason
The inspection was conducted as a complaint-related investigation following a self-reported incident received on 2023-03-01 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with standards related to supervision of residents, specifically that two residents eloped from the facility during renovations. Violations were issued and a plan of correction was required to address the deficiencies.
Complaint Details
Complaint related: Yes. The evidence supported the self-report of non-compliance with standards. Two residents eloped from the facility through a side exit during renovations.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering from the premises. |
Report Facts
Date of self-reported incident: Mar 1, 2023
Date of inspection: Apr 25, 2023
Number of residents who eloped: 2
Time of elopement incident: 1640
Plan of correction submission timeframe: 5
Posting timeframe: 5
Review request timeframe: 15
Inspection Report
Renewal
Census: 40
Deficiencies: 15
Apr 25, 2023
Visit Reason
The inspection was a renewal inspection conducted on April 25, 2023 and May 11, 2023 to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple areas of non-compliance including failure to obtain required written approvals for residents with serious cognitive impairments, incomplete resident records, lack of first aid certification for staff, failure to post current on-site person in charge, missing psychotropic medication treatment plans, incomplete personal and social information, delayed resident orientation, unsigned individualized service plans, failure to post weekly menus, building maintenance issues, inadequate temperature control, and failure to post inspection findings.
Deficiencies (15)
| Description |
|---|
| Failed to obtain prior written approval before placing Resident #2 with serious cognitive impairment in a safe, secure environment. |
| Failed to document justification for placement of Resident #1 in safe, secure environment. |
| Resident records #1 and #3 lacked required written disclosure and signatures. |
| Staff #3 did not have evidence of current first aid certification within 60 days of employment. |
| Failed to post the name of the current on-site person in charge accurately. |
| Resident #4 prescribed psychotropic medication without a treatment plan. |
| Personal and social information forms for Residents #1, #3, and #4 were incomplete. |
| Resident #6 did not receive orientation upon admission until 12 days later. |
| Uniform assessment instrument forms for Residents #3 and #4 were not signed by assessor or administrator. |
| Individualized service plans for Residents #1, #5, and #6 lacked resident or representative signatures. |
| Individualized service plan for Resident #3 was not reviewed at least every 12 months or as condition changed. |
| Menu for the current week was not posted during inspection. |
| Interior door from dining area to courtyard did not latch or lock properly. |
| Room temperature in dining area was 66 degrees, below required 72 degrees. |
| Findings of the most recent inspection were not posted in the facility. |
Report Facts
Number of residents present: 40
Number of resident records reviewed: 6
Number of staff records reviewed: 5
Number of resident interviews conducted: 3
Number of staff interviews conducted: 4
Room temperature: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Current inspector conducting the inspection |
| Staff #3 | Employee lacking first aid certification | |
| Staff #1 | Acknowledged resident orientation delay and inspection findings not posted | |
| Staff #5 | Acknowledged door was not working properly |
Inspection Report
Renewal
Census: 30
Deficiencies: 7
Jun 13, 2022
Visit Reason
The inspection was a renewal type conducted on June 13 and June 17, 2022, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple areas of non-compliance including failure to post required documents, lack of current certification listings, failure to post the name of the person in charge, missing weekly menus and menu substitutions, incomplete medication administration records, and maintenance issues such as exposed wires and peeling flooring. Corrective actions were taken on site or planned with measures to prevent recurrence.
Deficiencies (7)
| Description |
|---|
| Facility failed to post certain documents related to the terms of the license including the most recent inspection findings. |
| Facility failed to have a listing of all staff with current First Aid and CPR certification posted. |
| Facility failed to post the name of the current on-site person in charge. |
| Facility failed to have the menu for the current week posted. |
| Facility failed to document menu substitutions on the posted menu. |
| Facility failed to include all required documentation on the Medication Administration Record (MAR) for multiple residents and medications. |
| Facility failed to maintain the interior and exterior of the building in good repair, including exposed alarm system wires and peeling vinyl flooring. |
Report Facts
Number of residents present: 30
Number of resident records reviewed: 5
Number of staff records reviewed: 7
Number of resident interviews: 2
Number of staff interviews: 3
Inspection Report
Monitoring
Census: 32
Deficiencies: 5
May 6, 2021
Visit Reason
A monitoring inspection was initiated to review compliance with applicable standards and laws using an alternate remote protocol due to a state of emergency health pandemic.
Findings
The inspection identified multiple non-compliances including outdated staff risk assessments, incomplete individualized service plans for residents, missing diagnosis or indications on medication orders, incomplete PRN medication orders, and failure to obtain timely criminal history record reports for employees.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure the risk assessment for staff was no older than 30 days. |
| Facility failed to ensure the individualized service plan included all assessed needs for two of three residents. |
| Facility failed to ensure physician or prescriber orders identified diagnosis, condition, or specific indications for administering each drug. |
| Facility failed to ensure physicians or prescriber orders for PRN medications included the exact dosage for medication administered by medication aides. |
| Facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee. |
Report Facts
Inspection dates: 3
Staff risk assessment date: 11
Staff hire date: 12
Plan of correction date: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Inspector | Current inspector conducting the inspection |
| Staff #1 | Acknowledged deficiencies related to TB risk assessment, medication orders, and individualized service plans | |
| Staff #6 | Staff with outdated TB risk assessment and missing criminal history record report | |
| Executive Director | Executive Director | Responsible for implementation and monitoring of corrective actions |
| Director of Resident Care | Director of Resident Care | Responsible for implementation and monitoring of corrective actions |
| Business Office Manager | Business Office Manager | Responsible for auditing employee files and compliance with standards |
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