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. 15, 2021

Complaint Related: Yes

Areas Reviewed:

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

Comments:

An unannounced complaint inspection was conducted on 12-15-21 in response to a complaint that was received by the regional licensing office. Staff interviews and records reviews were conducted regarding an allegation of resident care. The The information gathered during the investigation did not support the allegation, so the complaint is determined to be "not valid". There were other violations cited during the inspection. 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 #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on documents reviewed and staff interviewed, 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 any resident. Evidence: 1. On 12-15-21 during interview with CS#1, for reported wound and resident care for resident #1, CS #1 informed the inspectors resident #2 also was identified with wound care needs on 10-26-21. 2. A review of resident #1 and 2?s Progress Noted documented residents were receiving Hospice services. Progress Notes dated 10-26-21 at 11:42 a.m., documented ?resident has a breakdown on bottom, hospice called?CS #1 also contacted. 3. Staff #4 also documented on 10-26-21 at 10:40 p.m., ?resident had pressure sore for weeks now?CNAs was applying calmoseptine to the buttocks, pressure grew to the size of a quarter & about 1 to1 ? inch depth?covered with 4 X 4 gauge pad and the correct border sacrum dressing.? Staff also documented informing staff in charge to contact Hospice and not knowing if agency had left supplies for dressing change. 4. Resident #1?s record and facility communication log, did not include documentation by staff or agency of resident #1?s sacral wound prior to staff #2?s documentation on 10-26-21. 5. Resident #2?s record Progress Notes documented on 9-26-21 at 8:00 p.m. by CS #1, a ?sacral wound measurement done, area of tunneling healed?? 6. Staff #4 documented in resident #2?s Progress Notes on 10-26-21 at 11:10 p.m., ?resident had pressure sore for weeks, tried my best to keep it dry with 4 X4 guage pad & the correct dressings?? Staff also documented informing charge nurse to contact hospice, continued monitoring and ?the wrong dressing is being applied to the buttocks of this resident?? 7. CS #1 documented on 10-26-21, ?dressing changes done as ordered 5x weekly and as needed by RN on weekends. ?.staff to notify Hospice if dressing comes off. 8. The facility did not report resident #1?s sacral ulcer documented 10-26 21 to the licensing office. The facility also did not report resident #2?s sacral ulcer that was documented as healed on 9-26-21. The facility also did not report resident #2?s sacral ulcer documented in the record on 10-26-21. 9. Staff #1 reminded to forward to the licensing office reportable incidents.
Plan of Correction:	Nursing and Administrative staff will be in-serviced on VDSS regulation regarding reporting any major incidents that negatively affects or threatens the life, health or welfare of any resident. Staff will be instructed to immediately report any and all questionable wounds, visits from the fire department, Police, Adult Protective services or resident being sent to ER to Nursing Supervisor and Administrative Staff to ensure proper care is started in a timely manner and reported to VDSS if applicable. Nursing staff will be instructed to utilize the 24 hour communication log as well as verbal notification of these incidents to ensure all nursing staff are aware. February 15, 2022