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: Oct. 5, 2021 , Oct. 12, 2021 and Dec. 15, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An non-mandated complaint investigation was conducted on 10-5-21. The administrator was contacted but was not present, the staff person in charge was provided a list of the requested documents. The licensing inspector emailed the staff person-in-charge a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on 12-15-21. The evidence gathered during the investigation supported the non-compliance with standards or law, and violations were issued. Any violations not related to the but identified during the course of the investigation can be found on the violation notice. 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 1-9-22.

Violations:

Standard #:	22VAC40-73-280-A
Complaint related:	Yes
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure it had staff adequate in knowledge, skills and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental and psychological well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with this chapter (Part IV-Staffing and Supervision). Evidence: 1. The residents? roster provided for a complaint of insufficient staff in the facility documented 43 resident. The resident roster documented the following acuity levels: (a) 6 residents receiving hospice services, (b) 3 non-ambulatory residents, (c) 14 residents documented as fall risk and (d) 4 residents requiring 30- minute checks. 2. According to collateral reports and interviews, there was only 1 staff in the facility on the night of 9-11-21 for the 10 p.m. to 6 a.m shift. 3. The staff roster provided documented 2 staff for the 10 p.m. to 6 a.m. shift on the night of 9-11-21. Interviews with various staff revealed there was only 1 staff in the facility to provide care for 4. According to interviews and police report, calls were made management staff and the administrator/licensee. There was no response from management staff. Contact was made with the administrator/licensee who was informed of the staffing shortage at the facility. The report documented, the administrator- licensee stated living two hours away ? there other staff who lived closer and wanted to know what did the officer what him to do. 5. Interview with staff revealed, a resident locked themselves in another resident?s bathroom and took apart the doorknob and staff needed the officer?s assistance because staff could not open the bathroom door. 6. Staff #1 acknowledged facility did not have sufficient staff on night of 9-11-21
Plan of Correction:	Employment ads will be placed on Zip Recruiter, Linked In and Indeed to advertise for additional staff. (already done) Facility has contracted with a local nursing agency to assist with filling openings in the direct Care/C.N.A. schedule. (already done) Administrative staff will continue to pick up shifts in which there is no coverage until staffing is sufficient. Facility will hire qualified candidates to alleviate the need for OT by current staff and to fill shifts in need of proper staffing, January 21, 22 and ongoing