Inspection Reports for Dominion Village at Williamsburg
4132 Longhill Rd, Williamsburg, VA 23188, United States, VA, 23188
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Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 5, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-04-11 regarding allegations related to personnel at the facility.
Findings
The investigation found non-compliance with personnel standards, specifically that a direct care staff member did not have documentation of required qualifications. Violations were issued based on these findings.
Complaint Details
The complaint was substantiated. Evidence showed Staff #2 worked from 2023-10-07 through 2024-06-10 without documentation of direct care qualifications. Staff #1 acknowledged this lack of documentation.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure direct care staff meet one of the requirements in this subsection, as Staff #2's record lacked documentation of direct care qualifications. |
Report Facts
Number of staff records reviewed: 2
Number of interviews conducted with staff: 1
Inspection Report
Monitoring
Census: 37
Deficiencies: 1
Jun 5, 2025
Visit Reason
The inspection was conducted as a monitoring visit following self-reported incidents received by VDSS Division of Licensing regarding allegations in Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with regulations for licensed assisted living facilities, specifically related to two residents who eloped through an emergency door due to alarm failures and staff oversight. Violations were issued based on these findings.
Deficiencies (1)
| Description |
|---|
| Failure to ensure compliance with all regulations for licensed assisted living facilities and terms of the license; specifically, two residents requiring placement in a safe, secure unit were able to elope through the emergency door due to alarm not being on and staff not noticing. |
Report Facts
Number of residents present: 37
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Inspector conducting the monitoring inspection |
Inspection Report
Renewal
Census: 33
Deficiencies: 6
Jun 5, 2025
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for the facility's license renewal.
Findings
The inspection identified multiple violations including failure to ensure staff had current first aid certification, lack of required psychotropic treatment plans, missing preliminary plans of care, unsigned individual service plans, failure to post dated menus, and lack of a current annual fire inspection.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure each direct care staff member had current first aid certification within 60 days of employment. |
| Facility failed to admit or retain individuals with prohibitive conditions without required documentation, specifically missing psychotropic treatment plan for Resident #3. |
| Facility failed to develop preliminary plans of care within seven days prior to admission for Residents #1 and #2, and missing POA signature for Resident #4. |
| Individual Service Plan (ISP) for Resident #1 was not signed and dated by resident or legal representative. |
| Menus for meals and snacks for the current week were not dated, posted, or recorded for substitutions. |
| Facility failed to comply with Virginia Statewide Fire Prevention Code by not having an annual fire inspection since 1/9/2024. |
Report Facts
Number of residents present: 33
Number of resident records reviewed: 8
Number of staff records reviewed: 3
Number of resident interviews: 2
Number of staff interviews: 3
Date of last annual fire inspection: Jan 9, 2024
Inspection Report
Monitoring
Census: 1
Deficiencies: 1
Feb 14, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care and related services standards, following a self-reported incident received on 2024-11-04 regarding allegations in resident care.
Findings
The inspection found non-compliance with applicable standards related to supervision of resident schedules, including prevention of falls and wandering. A violation was documented regarding a resident exiting the building through a delayed egress door without adequate supervision.
Deficiencies (1)
| Description |
|---|
| Failed to provide supervision of resident schedules, including attention to specialized needs such as prevention of falls and wandering from the premises. |
Report Facts
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: 0
Feb 14, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-02-10 regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint related to Resident Care and Related Services; the allegations were not substantiated.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 0
Staff interviews conducted: 1
Resident interviews conducted: 0
Inspection Report
Monitoring
Deficiencies: 2
Feb 14, 2025
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in Resident Care and Related Services.
Findings
The investigation did not support the self-report of non-compliance; however, violations unrelated to the self-report were identified. Two deficiencies were cited related to failure to ensure the uniform assessment instrument was properly signed and failure to complete a comprehensive Individualized Service Plan within 30 days of admission.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the uniform assessment instrument (UAI) was completed and signed by a qualified assessor. |
| Facility failed to complete a comprehensive Individualized Service Plan (ISP) within 30 days after admission including a description of needs as identified by the UAI. |
Report Facts
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
Monitoring
Census: 30
Deficiencies: 2
Jul 8, 2024
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care, related services, and building and grounds standards following self-reported incidents regarding allegations in resident care.
Findings
The investigation supported the self-report of non-compliance with standards and violations were issued related to supervision of a wandering resident and failure to provide air conditioning in all resident areas.
Deficiencies (2)
| Description |
|---|
| Facility failed to provide supervision of resident schedules and specialized needs of wandering from the facility. |
| Facility failed to provide air conditioning for all areas used by residents including common areas; temperature exceeded 80 degrees Fahrenheit. |
Report Facts
Number of residents present: 30
Resident #1 Elopement Risk Evaluation score: 10
Resident #1 Elopement Risk Evaluation score: 18
Temperature readings: 81
Temperature readings: 78
Temperature readings: 76
Inspection Report
Renewal
Deficiencies: 8
May 29, 2024
Visit Reason
The inspection was conducted as a renewal of the facility's license to ensure compliance with applicable standards and regulations.
Findings
The inspection identified multiple violations including failure to document justification for placement of residents with serious cognitive impairment, incomplete tuberculosis risk assessments for staff, incomplete Uniform Assessment Instrument and Individualized Service Plan updates, lack of current health inspection, unsecured medication storage, incomplete fire and emergency drill documentation, and failure to post the facility license as required.
Deficiencies (8)
| Description |
|---|
| Failed to document justification for placement of a resident with serious cognitive impairment in a safe, secure environment. |
| Failed to ensure staff submitted valid tuberculosis risk assessments prior to employment and annually. |
| Uniform Assessment Instrument (UAI) was incomplete regarding type of assistance needed for bathing. |
| Failed to update Individualized Service Plan (ISP) at least annually and as needed for significant changes. |
| Facility did not have a current health inspection from the Virginia Department of Health. |
| Medications and dietary supplements were stored unsecured with medication room door unlocked. |
| Fire and emergency evacuation drills were not conducted or documented for all required shifts and quarters. |
| Facility license was not posted on the premises as required. |
Report Facts
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews conducted: 3
Number of staff interviews conducted: 3
Number of unsecured medication bins observed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Conducted the inspection |
| Staff #1 | Acknowledged lack of current health inspection and missing facility license posting | |
| Staff #3 | Acknowledged medication room door was unlocked and medications unsecured |
Inspection Report
Deficiencies: 8
Mar 1, 2024
Visit Reason
The inspection was conducted as a regulatory oversight visit categorized as 'Other' to review compliance with various administrative, personnel, resident care, and related service standards. It included investigation of a self-reported incident received on 2024-01-05 regarding allegations in Resident Care and Related Services.
Findings
The investigation did not substantiate the self-reported non-compliance but identified several violations unrelated to the self-report. Violations included failures in employee criminal history background checks, disclosure statements to residents, admission documentation for prohibitive conditions, sex offender screening, uniform assessment instrument completion, individualized service plans, and annual review of residents' rights.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee. |
| Facility failed to prepare and provide a disclosure statement to prospective resident and legal representative, with written acknowledgement retained in the resident's record. |
| Facility failed to admit or retain individuals with prohibitive conditions without required documentation, specifically missing psychotropic treatment plans for medications. |
| Facility failed to ascertain prior to admission whether a potential resident is a registered sex offender. |
| Facility failed to ensure the uniform assessment instrument (UAI) was completed and signed by the administrator or designee. |
| Facility failed to ensure the comprehensive individualized service plan (ISP) included all assessed needs, missing physical therapy services. |
| Facility failed to ensure the Individualized Service Plan (ISP) was signed and dated by the resident or legal representative. |
| Facility failed to ensure the rights and responsibilities of residents were reviewed annually with each resident or legal representative and staff. |
Report Facts
Number of resident records reviewed: 2
Number of staff records reviewed: 2
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 23, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to medication management practices at Dominion Village at Williamsburg.
Findings
The facility failed to implement its written medication management plan, resulting in multiple instances where residents did not receive prescribed medications on time. Several residents had documented missed doses due to unavailable medications.
Complaint Details
The visit was complaint-related. The complaint was substantiated as the facility did not follow its medication management plan, resulting in missed medication doses for residents.
Deficiencies (1)
| Description |
|---|
| Failure to implement the written medication management plan to ensure timely ordering and administration of medications, leading to missed doses for multiple residents. |
Report Facts
Missed medication dates: 34
Inspection Report
Routine
Deficiencies: 17
Jun 23, 2023
Visit Reason
The inspection was a routine regulatory visit to review compliance with Virginia assisted living facility regulations, including administration, resident care, staffing, and safety standards.
Findings
The facility was found deficient in multiple areas including failure to conduct annual resident assessments, incomplete staff training and certifications, missing documentation in resident records such as disclosure statements, interviews, physical exams, and medication treatment plans, as well as inadequate maintenance of first aid kits.
Deficiencies (17)
| Description |
|---|
| Failed to ensure a resident was assessed annually for continued appropriateness for residence on the special care unit. |
| Failed to provide and retain signed disclosure statements for prospective residents. |
| Failed to ensure all direct care staff completed at least 18 hours of annual training. |
| Failed to ensure annual tuberculosis risk assessments were completed for staff. |
| Failed to ensure direct care staff obtained first aid certification within 60 days of employment. |
| Failed to maintain a current and posted list of staff with first aid and CPR certification. |
| Failed to document admission interviews with residents or legal representatives. |
| Failed to provide written assurance of appropriate licensing prior to resident admission. |
| Failed to admit or retain individuals with prohibitive conditions without required documentation. |
| Failed to ensure physical examinations were completed within 30 days prior to admission. |
| Failed to ascertain whether potential residents were registered sex offenders prior to admission. |
| Failed to have signed resident agreements at or prior to admission. |
| Failed to provide orientation to new residents and their legal representatives upon admission. |
| Failed to conduct annual assessments and reassessments using the Uniform Assessment Instrument (UAI). |
| Failed to review and update individualized service plans (ISP) at least annually and after significant changes. |
| Failed to include required documentation on Medication Administration Records (MAR) for multiple residents. |
| Failed to ensure first aid kits were checked monthly and contained all required items and were not expired. |
Report Facts
Training hours required: 18
Fluid restriction: 34
Fluid restriction: 48
Expiration date: 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Meredith Leary | FNP | Completed psychotropic medication treatment plans for residents #7 and #3 |
| Alyshia E Walker | Inspector | Current inspector conducting the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 8, 2023
Visit Reason
The inspection was conducted as a complaint-related investigation reviewing administration, personnel, staffing, buildings, grounds, and complaint investigation standards.
Findings
The facility was found deficient in ensuring all direct care staff completed at least 18 hours of annual training and failed to ensure staff reviewed residents' rights and responsibilities annually, based on staff records and interviews.
Complaint Details
The visit was complaint-related as indicated, but the specific substantiation status is not stated.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure all direct care staff attended at least 18 hours of training annually. |
| Facility failed to ensure staff reviewed rights and responsibilities of residents annually. |
Inspection Report
Renewal
Census: 6
Deficiencies: 5
Mar 30, 2022
Visit Reason
An unannounced mandated renewal inspection was conducted to assess compliance with licensing regulations for the assisted living facility.
Findings
The inspection identified multiple violations including failure to ensure annual tuberculosis risk assessments for staff, incomplete individualized service plans for residents, lack of annual review of resident rights with staff, unsecured medication storage, and maintenance issues in the facility physical plant.
Deficiencies (5)
| Description |
|---|
| Failure to ensure each staff person annually submits tuberculosis risk assessment results. |
| Comprehensive individualized service plan did not include expected outcome and time frame. |
| Failure to ensure annual review of resident rights with staff persons documented. |
| Medication storage area in resident apartment was not locked. |
| Facility interior and exterior areas were not maintained in good repair, including broken wood, stained carpet, scratched walls, and rusted fixtures. |
Report Facts
Staff records reviewed: 4
Resident records reviewed: 6
Residents observed: 6
Staff observed: 4
Inspection Report
Renewal
Deficiencies: 6
Apr 13, 2021
Visit Reason
A renewal inspection was initiated on April 13, 2021 and concluded on April 14, 2021 to assess compliance with applicable standards and laws for Dominion Village at Williamsburg.
Findings
The inspection identified multiple violations including failure to ensure direct care staff annual training, tuberculosis screening, first aid certification, individualized service plan signatures, resident rights acknowledgments, and fire drill frequency compliance.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure all direct care staff attended at least 18 hours of annual training. |
| Facility failed to ensure annual tuberculosis risk assessment documentation for staff. |
| Facility failed to ensure direct care staff received first aid certification within 60 days of employment. |
| Facility failed to ensure individualized service plans were signed and dated by residents or legal representatives. |
| Facility failed to ensure resident rights and responsibilities were reviewed annually and signed by residents or legal representatives. |
| Facility failed to ensure fire and emergency evacuation drills were conducted monthly and on all required shifts. |
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