VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Colonial Manor
8679 Pocahontas Trail
Williamsburg, VA 23185
(757) 476-6721

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: July 29, 2019 and July 30, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 63.2 Protection of adults and reporting. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

An unannounced renewal inspection was conducted on 7-29-19 (ar 7:30 am/dep 6:00pm) and 7-30-19 (ar 9:50 am/dep 5:30 pm). The facility census on 7-29-19 was 51. The administrator was not present but came later but left prior to the exit interview and was not present on the day two of the inspection. A tour of the facility was conducted, a medication pass observation, resident and staff record and interviews conducted, breakfast meal observed on the day one. The violations, concerns and or other issues were reviewed throughout the inspection process with the administrator, staff and consultant. The acknowledgement form was signed on day one by the consultant and on day two by the assistant to the administrator. Comment: The inspector suggested the facility review its medication dosing schedule, residents who attend day support and depart medication should be given earlier and those who remain and do not go out the facility may want to change administrator to a later time; reduce the stress on one staff trying to administer medication, apply creams and eyedrops within the current dosing time. Facility also reminded of the individual who completes the healthcare oversight should not be the individual who also reviews the and signs the uniformed assessment instrument and also completing the individualized service plans. Facility staff reminded to review the regulation regarding revisions and changes: infection control requirements, staff mandated training; sex offender reminder information; drug guide book and updating medication administration record when medication/treatment is discontinued. Also administrator reminded of presence for the day-to-day operation of the facility. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible. Plan of correction due within 10 days.

Violations:

Standard #:	22VAC40-73-100-A
Description:	Based on interview, the facility failed to ensure it develop, in writing, and implement an infection control program addressing the surveillance, prevention, and control of disease and infection that is consistent with the federal Centers for Disease Control and Prevention (CDC) guidelines and the federal Occupational Safety and Health Administration (OSHA) bloodborne pathogens regulations. Evidence: 1. On 7-30-19 during a review of staff training records with staff #2 and #10, it was revealed the facility did not develop an infection control program per the new regulation requirement, the administrator did not review the policy annually and the administrator had not appointed a staff as the facility's point of contact and conducted orientation and training of staff on policy, with a mandated 2 hours of training. 2. Staff #2 acknowledge the facility did not have an infection control policy as outlined in the regulation.
Plan of Correction:	Facility will develop Infection Control Program consistent with the CDC and OSHA guidelines. All facility staff will be in-serviced with the mandated 2 hours of training. Nurse Overseer will train all current staff and designate 1 day a month to train incoming new staff to ensure all staff receive training.
Standard #:	22VAC40-73-50-B
Description:	Based on record review and staff interview, the facility failed to ensure written acknowledgement of the receipt of the disclosure by the resident or his legal representative shall be retained in the resident's record. Evidence: 1. On 7-30-19 during a review of the sample residents' record with staff #2, resident #7's record was missing written acknowledgement of the receipt of the facility's disclosure. 2. Staff #2 acknowledge the disclosure was not in resident #7's record.
Plan of Correction:	Disclosure Statements will be included with information given to all potential new residents/family members at time of tour to ensure disclosure statement is received in a timely manner. Asst. Administrator will add Signed & dated section for disclosure statement to 7 points covered checklist and 7 points covered checklist will be added to residents chart upon admission. Disclosure Statement section added to Pre Admission area of admission checklist by Asst. Administrator to ensure disclosure statement is received prior to admission.
Standard #:	22VAC40-73-120-A
Description:	Based on record review, document review and staff interview, the facility failed to ensure a record contained written acknowledgement of orientation and training. Evidence: 1. On 7-30-19 during a review of the sample staff record with staff #2, staff #7's record was missing acknowledgement of orientation and training. 2. Staff #2 acknowledge staff #7's record did not have acknowledgement of orientation and training.
Plan of Correction:	Asst. Administrator will schedule weekly New Hire Orientation to ensure all new hires within the last 7 days are oriented within the 1st 7 days of employment.
Standard #:	22VAC40-73-250-C
Description:	Based on record review and staff interview, the facility failed to ensure a staff record included all required personal and social data. Evidence: 1. On 7-30-19 during a review of the sample staff records with staff #2, staff #7's record was missing a signed copy of staff's job description. 2. Staff #2 acknowledge the job description was missing from staff #7's record.
Plan of Correction:	Asst. Administrator will schedule weekly New Hire Orientation to ensure all new hires within the last 7 days are oriented within the 1st 7 days of employment.
Standard #:	22VAC40-73-250-D
Description:	Based on record review, document review and staff interview, the facility failed to ensure staff person on or within seven days prior to the first day of work at the facility shall submit the results of a risk assessment, documenting the absence of tuberculosis (tb) in a communicable form. Evidence: 1. On 7-30-19 during a review of the sample staff record with staff #2, staff #6's tb was dated 12-21-18; however, staff #6's date of hire was noted as 12-4-18. 2. A review of staff #8's record with staff #2, staff #8's tb was dated 2-14-19; however, staff #8's date of hire was noted 2-8-19. 3. Staff #2 acknowledged staff #6 and #8's tb information was after staff's date of hire.
Plan of Correction:	Asst. Administrator will add TB Screening/Questionnaire to all employment applications to ensure risk assessment is completed on or within 7 days prior to first day of work.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, document review and staff interview, the facility failed to ensure a direct care staff maintained current certification in first aid from an approved source noted in the regulation. Evidence: 1. On 7-30-19 during a review of the posted first aid and cardiopulmonary resuscitation (cpr) listing with staff #2 and #10, staff 9's first aid had expired 9-14-18. According to staff #10, staff #9 did not attend the class scheduled on 7-25-19. 2. Staff #2 and #10 acknowledge staff #9's first aid was not current.
Plan of Correction:	Asst. Administrator will create a spreadsheet of all employees to include but not limited to: Hire Date, RMA/C.N.A. license expiration date, food handlers card expiration date, 1st Aid & CPR expiration dates, etc. to ensure employee is reminded of need for renewals in a timely manner.
Standard #:	22VAC40-73-310-H
Description:	Based on record review, document review and staff interview, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions per the regulation. Evidence: 1. On 7-30-19 during a review of the sample resident records with staff #2 and #10, resident 6's record included a physician's order for Ativan. Further review of the record did not include a psychotropic treatment plan. 2. Staff #2 and 10 acknowledge the facility did not have a psychotropic treatment plan for Ativan for resident #6.
Plan of Correction:	Asst. Administrator will update Physician?s Order to include Psych Treatment Plan Form to ensure Psych Treatment Plan is signed at time of ordering by physician.
Standard #:	22VAC40-73-410-A
Description:	Based on record review and staff interview, the facility failed to ensure a resident's record included acknowledgement of having received the orientation to the facility. Evidence: 1. On 7-30-19 during a review of the sample residents' record with staff #2, resident #7's record was missing signed documentation of having received an orientation to the facility upon admission. 2. Staff #2 acknowledge, resident #7's record was missing documentation of having received orientation to the facility.
Plan of Correction:	Asst. Administrator will add an additional area to the Admission Checklist for Resident Oriented to facility upon admission and also add to 7 points checklist of requirements at time of admission to ensure resident is oriented to facility at time of admission or prior to admission.
Standard #:	22VAC40-73-430-H-1
Description:	Based on document review and staff interview, the facility failed to ensure the discharge statement was completed and included all required information per the regulation. Evidence: 1. On 7-29-19 during a review of the sample residents' record with staff #5 and #10, resident #8's discharge statement was missing the date of notification, method of notification, reason for discharge and signed by the licensee or administrator. 2. Staff #10 acknowledge the discharge statement for resident #8 was missing information and not signed by the appropriate individual.
Plan of Correction:	Discharge Statement will be added to Record of Death Form by Asst. Administrator to ensure all appropriate information is included and signed by licensee at time of residents discharge/death.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, document review and staff interview, the facility failed to ensure the individualized service plan (ISP) included all assessed needs of the resident. Evidence: 1. On 7-29-19 during a review of the sample residents' record with staff #10, resident #1's uniformed assessment instrument (uai) dated 3-25-19 noted mechanical help with bathing. A review of the resident's ISP dated 3-6-19 did not include bathing need. The uai dated 3-25-19 not resident need assistance with laundry, however, the ISP dated 3-6-19 noted the resident does own laundry. 2. On 7-29-19 a review of resident #4's record with staff #10, resident's uai dated 3-6-19 and individualized service plan (ISP) daed 3-6-19 indicated medication administered by medication aide and licensed staff. However, during medication pass on 7-29-19, staff #3 stated resident 's Aveeno cream was kept at bedside and resident self-administered cream. A review of the ISP did not include resident self-administering. 3. A review of resident #5's record on 7-29-19 with staff #10 and on 7-30-19 with staff #2, the resident's ISP did not include the resident's risk management plan. 4. Staff #10 acknowledged resident #1, #4 and #5's ISP not including all assessed needs.
Plan of Correction:	1. Residents whose UAI is completed by a licensed Social Worker for Auxiliary Grant ( Public Pay) purposes will be reviewed by Asst. Administrator and Nurse Overseer to ensure residents needs and abilities are accurately documented. When discrepancies are noted, facility will contact UAI completer to request the UAI be adjusted to reflect the residents current abilities or lack of. 2. Residents not having self administering privileges, will not be allowed to keep creams/lotions, etc. at bedside unless assessment by Nurse Overseer has been completed and deems resident competent to administer. 3. Any/All residents being admitted with a NGRI status will require service provided to include the risk management plan prior to admission. NGRI Risk Management Plan (if applicable) will be added to Pre-Admission area of admission checklist by Asst. Administrator to ensure information is received prior to admission.
Standard #:	22VAC40-73-450-E
Description:	Based on record review, document review and staff interview, the facility failed to ensure the individualized service plan was reviewed and updated as needed. Evidence: 1. On 7-29-19 during a review of the sample residents' record with staff #10, resident #1's individualized service plan (ISP) was updated to include resident's homehealth services. Further review of resident #1's record revealed resident's homehealth services for skilled nursing, occupational therapy and physical therapy services began 3-6-19 and was continued through 5-5-19 and was so documented on the resident's 3-6-19 ISP. However, an extension contract for homehealth services was not in the record and the ISP was not updated to indicate discontinued or continue need for services. 2. Staff #10 acknowledge resident #1's ISP was not updated to reflect resident's service need or discontinuance of services.
Plan of Correction:	During weekly home health meetings, any new or extended services will require a 485 within 48 hours to ensure appropriate update to services/discharge on ISP. Assistant Administrator will update ISP?s following weekly home health meetings as needed.
Standard #:	22VAC40-73-870-C
Description:	Based on observation and interview the facility failed to ensure adequate provision for the collection and legal disposal of garbage was made. Evidence: 1. On 7-29-19 during a tour of the facility with staff #1, the inspector observed in the rear of the facility an area with rolled up carpet, and other trash/debris that needed to be collected. 2. Staff #1 acknowledge the items needed to be removed from the backyard of the facility.
Plan of Correction:	Any/All trash/debris from renovations or resident move out will be disposed of in facilities garbage dumpsters. Any/all items too large for facilities dumpster will be hauled off to the local land fields for disposal or Administrator will acquire an additional dumpster for the oversized items as needed.