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: Dec. 19, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

An unannounced monitoring inspection was conducted on 11-20-19 (ar 08:00 a.m./dep 5:40p) and 11-20-19 (ar 09:30 am/dep 18:10 p.m). The administrator was not present but came and left prior to the exit interview. Administrator inquired of process for early compliance of current provisional license and receive a regular license.. A medication pass observation was conducted, a tour of the facility, meal observation (dinner on 11-21-19); staff and resident records review and staff and resident interviews were conducted. The acknowledgement form was signed on both days by the assistant administrator. Comments: LI reminded facility of the healthcare oversight being completed by the person who conducts the ISP and UAIs for the residents; fall risk should be conducted after each fall not only initially and annually; residents should be reminded annual of right to have a resident council and document informing of such. The activity should indicate the category of the activity and specific time of activity; resident should be assessed for the amount of time for residents to be spoon-fed by staff and ensure social data forms are updated with correct and current information. LI suggested resident rooms are checked to ensure rooms are not safety risk to resident, clutter removed and cleanliness of rooms to prevent pest and other vermin. 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 calendars of receipt. If you have any questions, contact the licensing inspector at (757) 439-6815. Plan of correction is due by 12-16-19.

Violations:

Standard #:	22VAC40-73-250-D
Description:	250-D.2.c Based on record review and staff interview, the provider failed to ensure one of four staff records reviewed submitted the results of a risk assessment, documenting that the staff is free of tuberculosis (tb) in a communicable form. Evidence: 1. On 11-21-19 during the review of the staff records with staff #2, staff #3 did not have documentation of an annual tuberculosis (tb) screening with documentation of the staff being free of tb in a communicable form. Staff #3's date of hire noted as 12-26-17, last documentation of tb was dated 8-10-18. 2. Staff #2 acknowledged staff #3's record did not have an updated tb results.
Plan of Correction:	TB risk assessment form will be done annually by all staff at the same time that Rights & Responsibilities and Sworn disclosure are done to ensure all staff TB assessments are done annually.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) included all assessed needs. Evidence: 1. On 11-20-19 during a review of residents' record with staff #2 and #10, resident #1's uniformed assessment instrument (UAI) dated 11-8-19 noted transferring section was blank; however, the individual service plan (ISP) dated 2-3-19 noted use of a rollator walker to transfer- occasionally. 2. A review of resident #3's UAI dated 7-9-19 noted dressing- human help/supervision, however the ISP dated 7-9-19 did not include this assessment. 3. A review of resident #3's UAI dated 3-8-19 noted orientation as occasional-decision making impaired, however, the ISP dated 3-19-19 did not include this information. 4. A review of resident #6's UAI dated 8-30-19 noted resident wandering; however, the ISP did not include this assessment. 5. A review of resident #8's UAI dated 1-12-19 noted bathing- supervision/human help; however, the ISP dated 1-129-19 noted use of grabbar- staff assist as needed and use of shower chair. 6. Staff #1 and #10 acknowledged the UAI and ISP discrepancies.
Plan of Correction:	Resident Care Leaders will receive ISP training to allow them to make changes to ISP in real time as changes occur.
Standard #:	22VAC40-73-650-B
Description:	Based on record review and staff interview, the facility failed to ensure the physician's order included all required information for a resident. Evidence: 1. On 11-20-19 during a review of resident #1's physician's orders (8-21-19) with staff #2 and #10, resident #1's Elocon (Mometasone) did not include a diagnosis. 2. Resident #2's physician order 10-8-19 for Lipitor (Atorvastatin) did not include a diagnosis.
Plan of Correction:	Nursing staff will be in-serviced on and trained that all orders received contain all information required. Any and all orders received not containing all the required information will be faxed back to ordering physician to add missing information. Orders without all information required will not be added to the MAR?s until all information required is present.
Standard #:	22VAC40-73-680-D
Description:	Based on record review and staff interview, the facility failed to ensure medications shall be administered in accordance with physician's or other prescriber's instructions for a resident. Evidence: 1. On 11-21-19 during a review of resident #1's November 2019 medication administration record (mar), the resident's Fluticasone nasal spray noted the 4-19-19 physician's order 2 spray each nostril; however, the record included physician's order dated 8-21-19 one spray each nostril. 2. Staff #3 acknowledge the discrepancy.
Plan of Correction:	RMA?s will be in-serviced on policy for transcribing medications to the MAR?s. Any and all orders received with all required information will be transcribed into MAR?S within 24 hours of receipt and doubled checked by a second RMA for accuracy. Physician?s Order sheet updated to include signatures from both RMA?s and to include a reminded to all physicians of the required information. Notice also added to physician?s order sheet stating that medications will not be dispensed without all required information.
Standard #:	22VAC40-73-680-M
Description:	Based on record review, observation and staff interview, the facility failed to ensure medications ordered for PRN administration was available at the facility for four of eight residents. Evidence: 1. On 11-21-19 during a review of the facility's medication cart with staff #3, resident #1's PRN, Atrovent (Ipratropium bromide) was not available in the facility for administration. 2. Resident #2's PRN antidiarrheal caplet and Triamcinolone were reviewed with staff #7 and #1 and were not available in the facility for administration. 3. Resident #3's PRN Miralax and Oxymetazoline Hydrochloride nasal spray were reviewed with staff #3 and were not available in the facility for administration. 4. Resident #4's PRN Artificial tears was reviewed with staff #3 and was not available in the facility for administration. 5. Staff #2, #3 and #7 acknowledged PRN medications were not available for residents #1, #2, #3 and #4.
Plan of Correction:	Nursing staff will be in-serviced on policy for ordering/reordering and checking PRN medications. Night shift nursing staff will be responsible for checking PRN Medications weekly and re-ordering when supply is getting low. Night Shift Monthly Checklist updated to reflect change from bi-weekly to weekly on the 7th, 14th, 21st and 28th of each month.
Standard #:	22VAC40-73-860-I
Description:	Based on observation and staff interview, the facility failed to ensure cleaning supplies and other hazardous materials were stored in a locked area. Evidence: 1. On 11-20-19 during a morning tour of the facility approximately 8:10 a.m., the inspector observed containers of "ZEP -heavy duty floor stripper concentrate" and containers of "pressure sensitive adhesive" located near the snack machine. The cleaning cart containing bleach and other unlabeled cleaning supplies was observed unmanned near the supply room near the beauty and barber shop. 2. Staff #1 acknowledged the items should not have been unattended.
Plan of Correction:	Lockable Housekeeping cart will be purchased to ensure all housekeeping chemicals are kept locked up and secured at all time. Any and all other chemicals/supplies Will be stored in locked housekeeping closet to ensure residents are not allowed accessibility.
Standard #:	22VAC40-73-870-A
Description:	Based on observation and staff interview, the facility failed to ensure the interior of the building was maintained in good in good repair. Evidence: 1. On 11-20-19 during the inspector's tour of the facility, the circular drains on the floor were observed to be loosed and posed a trip hazard. Drains were observed loose near rooms #27-28, #36 and #41-42. 2. Staff #1 acknowledged the safety issue with the drains being loose.
Plan of Correction:	Shorter screws will be put into floor drains to allow for a tighter fit to the floor since carpet has been replaced with vinyl flooring.
Standard #:	22VAC40-73-890-B
Description:	Based on observation and staff interview, the facility failed to ensure the exterior areas of the facility shall be adequately lighted for the safety and comfort of residents and staff. Evidence: 1. On 11-20-19 the inspector exited the facility approximately around 5:30- 5:40 pm and observed that their was no lighting on the exterior of the building that allowed the cars in the parking lot to be seen. The front porch was lighted, however, the rest of the grounds was totally dark. 2. Staff #8 and #9 were also outside when the inspector inquired why there was no light in the parking lot as their are safety issues for both staff, residents and guest who enter the facility at various evening and night hours. The cars in the parking not were not visible from the facility's porch. The facility is located on a rural unlighted road and surrounded by many trees. 3. On 11-21-19, staff #2 acknowledged the facility's lack of outdoor lighting on the premises.
Plan of Correction:	Parking Lot lights will be replaced with new LED lighting to provide adequate lighting in parking lot. New Photo Cell box added to ensure proper timing for lights to switch on/off.
Standard #:	22VAC40-73-940-A
Description:	Based on document reviewed and staff interview, the facility failed to ensure it complied with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: 1. On 11-21-19 during a review of the facility's fire inspection report with staff #2, the date of the facility's last fire inspection was dated 10-09-19. 2. Staff #2 acknowledge the fire inspection was last conducted 10-09-19.
Plan of Correction:	Fire Inspection date added to Google Calendar to remind of upcoming expiration to allow scheduling before expiration.