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: Feb. 12, 2020

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 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 1-28-20 (ar 07:31 am/dep 6:35 pm) and on 1-30-20 (ar 11:45 am/dep 2:25 pm). The census on day one was 50. A medication pass observation was conducted, breakfast meal was observed (waffle, bacon, egg, dry cereal of choice/ or oatmeal, coffee or juice). Staff and resident interviews and records were conducted. A tour of the facility was conducted, water temperatures conducted on day two. The administrator was present on both days of the inspection. The LA was present on day one of the inspection. The LI reviewed with staff violations and concerns throughout the visit on both days. The exit interview was conducted with the administrator and staff on both days of the inspection. The acknowledgement form was signed by the assistant to the administrator on both days. Comments: The administrator is making plans to renovate the facility and perhaps change the types of services/residents. the LA advise the administrator to submit the modification for the upcoming plans for the facility. The LI suggested the administrator have staff attend the ALF II class for training. The facility's medication management plan was discussed on day two, prn availability in facility; developer include date on ISP, and staff review and complete the healthcare oversight document including the exact days of the review, remove the DMAS, specialized services which is not provided. 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 within 10 days (2-10-20)

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on record review and staff interview, the facility failed to ensure it reported to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of a resident. Evidence: 1. On 1-28-20 during a review of resident #5's record with staff #2 and #3, the record noted resident #6 received services from a home health agency for wound care. 2. A review of resident #5's record noted home-health care treatment plan for wound to the resident's buttocks. The 485 document from home-health indicated services dates 3-21-19 thru 5-118-19 for stage II pressure ulcer to sacral. 3. Further review of resident #5's record noted another 485 home-health document for services dated 11-9-19 thru 1-7-20 for stage II/pressure ulcer to sacral. 4. A review of resident #5's individualized service plan (ISP) dated 3-20-19 indicated wound care services was discontinued on 1-7-20. 5. Staff #2 was asked by the LI on 1-28-20 whether stage II ulcer was reported to the licensing department. Staff acknowledged the incident reports for stage II for resident #5 were not reported.
Plan of Correction:	Assistant Administrator will be responsible for adding, changing, updating and discharging residents receiving home health services during weekly home health meetings with the various agencies providing services. A Home Health ISP Form has been created and will be utilized by Assistant Administrator when making changes to Home Health Services. Assistant Administrator will be responsible for notifying Licensing of any major incident that negatively affects or threatens the life, health, safety or welfare of a resident. Copies of all e-mails and faxes used for notification will be retained in a binder kept in the Assistant Administrators Office.
Standard #:	22VAC40-73-210-B
Description:	Based on record review and staff interview, the facility failed to ensure a direct care staff attended at least 18 hours of training annually. Evidence: 1. On 1-28-20 during the LA's review of staff records with staff #2, staff #7's record did not have documentation of at least eighteen (18) hours of required annual training. 2. Staff #7 had fourteen (14) hours of annual training. Further review of staff #7's training revealed staff had 1.5 hours of the required 2 hours of infection control training. 3. Staff #2 acknowledged staff #7 did not have all required all training hours.
Plan of Correction:	Staff members not attending mandatory scheduled training to ensure hours compliance, will be given a written warning of non-compliance and placed on 90 days probation. During those 90 days, staff will be responsible for making up the mandatory training hours or face termination.
Standard #:	22VAC40-73-440-H
Description:	Based on record review and staff interview, the facility failed to ensure it obtained an annual reassessment using the Uniformed Assessment Instrument (UAI), to determine whether a resident's need can continue to be met by the facility and whether continued placement in the facility is in the best interest of one of seven residents. Evidence: 1. On 1-28-20 during a review of residents' record with staff #3, resident #3 did not have an annual UAI in the record. 2. Further review of resident #3's record, the last UAI document was dated 10-29-18. 3. Staff #2 and #3 acknowledged the resident did not have an annual UAI in the record.
Plan of Correction:	A Public Pay UAI Request Made sheet will be created and placed in residents chart for staff member making the requests to document the dates and times that requests were made to show due diligence on the part of the facility. Any faxes that are made for these requests, will also be documented on this form and attached to the Public Pay UAI Request sheet.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure the comprehensive individualized service plan included all assessed needs for one of seven residents. Evidence: 1. On 1-28-20 during a review of residents' record with staff #2 and #3, resident #6's individualized service plan (ISP) did not include all assessed needs. 2. Resident #6's record included a physician's order dated 4-9-19 for skilled nursing, physical therapy and speech therapy services. The treatment plan from the home-health agency (485) noted physical therapy and occupational therapy services with dates 4-12-19 thru 6-10-19. However, the ISP dated 2-23-19 did not include physical therapy (PT) and occupational therapy (OT). 3. Further review of resident #6's record included another home-health treatment plan (485 document) with dates 10-29-19 thru 12-27-19. However, the ISP dated 5-18-19 did not include these services dates for new physical therapy (PT) and occupational therapy (OT). 4. The ISP did not indicate outcome date for any of the home health services that were discontinued (out come achieved date). The record also did not include physician's orders for home-health services for 7-21--19 thru 9-18-19 and 10-29-19 thru 12-27-19 per the home-health treatment plan. 5. Staff #2 and #3 acknowledged resident #6's ISP dated 2-23-19 and 5-18-19 did not include all assessed home-health services.
Plan of Correction:	Assistant Administrator will be responsible for adding, changing, updating and discharging residents receiving home health services during weekly home health meetings with the various agencies providing services. A Home Health ISP Form has been created and will be utilized by Assistant Administrator when making changes to Home Health Services. Physicians sending orders electronically will be required to send orders and/or hard scripts to the facility at time of order to ensure appropriate copies are retained.
Standard #:	22VAC40-73-470-A
Description:	Based on record review and staff interview, the facility failed to ensure, either directly or indirectly, that the health care needs of a resident was met for one of seven residents. Evidence: 1. On 1-28-20 during a review of residents' record with staff #2 and #3, the resident #6's record included physician's order for speech therapy (ST)/ cognitive therapy, dated 4-9-19. 2. Further review of the record revealed the services were not documented on the resident's individualized service plan (ISP). The record did not include services provided or discontinued. 3. Staff #2 and #3 acknowledged resident #6's record on 1-28-20 did not include services for speech therapy.
Plan of Correction:	Assistant Administrator will be responsible for adding, changing, updating and discharging residents receiving home health services during weekly home health meetings with the various agencies providing services. A Home Health ISP Form has been created and will be utilized by Assistant Administrator when making changes to Home Health Services. Physicians sending orders electronically will be required to send orders and/or hard scripts to the facility at time of order to ensure appropriate copies are retained.
Standard #:	22VAC40-73-860-G
Description:	Based on observation and staff interview, the facility failed to ensure the hot water at taps available to residents was maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F. Evidence: 1. On 1-30-20 during a check of the water temperatures with staff #1, the water temperature in room #32 was 122.9 degrees Fahrenheit (F). 2. The water temperature in room #35 was observed at 123.6 degrees F. 3. Staff #1 acknowledged the water temperatures were not within the required range.
Plan of Correction:	A monthly water heater temperature log will be created and utilized by maintenance staff to check and record all water temperatures at least monthly. Water temperatures testing above 120 degrees will be lowered and water temperatures testing below 105 degrees will be raised.
Standard #:	22VAC40-73-870-B
Description:	Based on senses and staff interview, the facility failed to ensure the building was free of from odor. Evidence: 1. On 1-28-20 at approximately 9:12 am, during the LA and LI's tour of the facility with staff #1, upon entering room #19, there was a smell of urine. 2. As the door remained open, the smell was noticeable while in the hallway. 3. On the afternoon of 1-28-20, the LI and staff #2 went to the room again, the smell of urine was again detected in room #19. 4. Staff #1 and #2 acknowledged room #19 had the smell of urine odor.
Plan of Correction:	Residents that are considered heavy wetter?s require frequent clothing and bed linen changes daily. Dependent upon the residents cognitive, understanding and reasoning abilities, one of the two following solutions will be applied: 1. Resident clothing/linen will be laundered on each shift 2. Resident soiled items will be placed in plastic bags, tied up and placed in residents hamper for staff to launder once daily.