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: 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. 63.2 Facilities and Programs.. 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 by two inspectors on 12-15-21 (ar 6:35 am/dep 5:30 p) The census was 41. A medication pass was observed, a tour of the facility conducted, staff and resident interviews conducted, the breakfast, lunch and dinner meal was observed. A review of resident and staff records were also reviewed, consultant reports, emergency preparedness documents and first aid kits. The administrator was not present. An initial exit was conducted with the assistant to the administrator and the nurse consultant. The acknowledgement form was completed and sent on 12-22-21 following a second exit meeting with the Assistant to the Administrator. Comments: Facility staff reminded to visit the public website for information from the department, inspector will continue to forward notices. 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. POC due within 10 days- 1-15-2022

Violations:

Standard #:	22VAC40-73-260-C
Description:	Based on observation and staff interviewed, the facility failed to ensure the first aid and cardiopulmonary resuscitation (CPR) listing was posted in the facility. Evidence: 1. On 12-15-21, staff #8 was asked where the first aid and CPR list was posted. Staff # 8 looked at the posting on various boards in the medication room but was not able to locate the list of staff who are certified in first aid and CPR. Staff #8 stated not knowing where the listing could be. 2. Staff #1 and CS-1 acknowledged the facility?s first aid and CPR listing was posted on the day of the inspection.
Plan of Correction:	Assistant Administrator will update and post 1st Aid & CPR certified staff listing which will include a DO NOT REMOVE warning. List will be posted in Nursing Office, Break room and Kitchen January 21, 2022
Standard #:	22VAC40-73-290-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the written work schedule included the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time. Evidence: 1. On 12-15-21 the dietary scheduled provided to the inspectors documented the first name only of staff working. 2. Staff #1 acknowledged the dietary schedule did not include all required information.
Plan of Correction:	Assistant Administrator will update dietary schedule template to include legend with first and last name of dietary staff. January 13, 2022
Standard #:	22VAC40-73-290-B
Description:	Based on observation and staff interviewed, the facility failed to ensure it posted the name of the current on-site person in charge, as provided for in the regulation, in a place in the facility that is conspicuous to the residents and to the public. Evidence: 1. On 12-15-21 at 06:50 a.m., the inspector looked for the posting of the staff person in charge when signing into the facility. Upon walking down the hallway, the inspector observed staff #3, #6 and #7 in staff?s breakroom and inquired who was in charge? 2. On the way to the nursing station/ medication room, staff # 3 stated being ?the med tech?. The bulletin board located outside the medication room listed staff names and shifts. The names of the individuals listed was for the day shift on 12-14-21. 3. Staff #1 acknowledged the staff in charge was not posted as required.
Plan of Correction:	Lead RMA on each shift will be responsible for updating nursing staff board to reflect correct on-site person in charge in the absence of administrative staff. January 21, 2022
Standard #:	22VAC40-73-320-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a risk assessment for tuberculosis (TB) was completed annually for a resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. On 12-15-21, a review of resident #2?s record revealed the resident?s TB was last dated 11-30-20. 2. CS-1 acknowledged resident #2?s TB information was not updated.
Plan of Correction:	Resident TB date ledger will be established and updated by Nurse overseer as TB?s are given or assessment done January 21, 2022
Standard #:	22VAC40-73-610-C
Description:	Based on observation, document reviewed and staff interviewed, the facility failed to ensure the daily menu, including snacks, for each resident met the current guidelines of the U.S. Department of Agriculture?s food guidance system or the dietary allowances of the Food and Nutritional Board of the National Academy of Sciences, taking into consideration the age, sex and activity of the resident. Evidence: 1. On 12-15-21 during the breakfast meal observation, residents were observed being served food in 2-ounce containers. The strawberry yogurt was served in 2 ?ounce clear plastic containers. Also observed was cut strawberries served in the 2- ounce cup, each cup contained 3 or 4 quartered section of a strawberry. Also observed were mini muffins and a hardboiled egg cut in half. Oatmeal was observed at the second seating. The menu documented the following: Yogurt, Assorted Muffins, 1 Boiled egg, ? C cold cereal or Oatmeal, fruit and coffee/milk/juice. 2. Staff #5 was inquired as to why the resident were being served in 2-ounce plastic containers and why the serving sizes were not the recommended serving size for adults? Staff stated doing what was instructed by the boss/ the administrator/licensee. Staff stated being aware of a previous conversation with the inspector regarding the requirements for serving for the residents. 3. The second seating lunch meal observation, residents were served a chef salad as documented on the menu. The size of the salad observed was that of a small side salad and included two to three, I inch long and ? wide strips of meat, julienne carrots, ice berg lettuce, and a half boiled egg. The lunch menu posted noted the following: Chef?s Salad, fruit/ coffee/tea/lemonade. 4. The dinner meal observation, residents were served, strips of baked tilapia, two potato wedges, cole slaw served in 2-ounce plastic containers, cornbread, macaroni and cheese; three residents were observed with split pea soup and corn bread only. The menu posted noted the following; Cajun Baked Fish baked macaroni and cheese, potato wedges, cole slaw, split pea soup, corn bread, chocolate cake, coffee/tea/lemonade. 5. The facility?s nutrition review dated January 29, 2021 documented facility menu do not contain 5 servings of vegetables and/or fruits; requested facility review each day?s menu and add items. Recommendations provided to facility for residents with puree diet: to serve entire meal at breakfast, lunch and dinner, whether the individual eats everything every time or not; cannot just serve a bowl of cereal or puree soup. Individuals should have option of tasting a variety of meal meals; plate each individual item for a meal. The report also documented some residents had experienced weight decline and/or are Hospice Care. 6. On 12-15-21, during the medication pass observation with staff #3, there were six residents on the assisted living cart who were receiving a supplement during the breakfast meal. 7. Interviews with residents on 12-15-21, several purchase food from outside the facility, some have snack items in their rooms and some also purchase items from the vending machine located in the facility.
Plan of Correction:	8 ounce plastic bowls will be purchased by facility to ensure the amounts served met the guidelines set forth by the USDA. USDA Dietary Guidelines for Americans 2020-2025 printed for staff referencing. Dietary Staff in-serviced on dietary guidelines and the importance of residents receiving daily/weekly allowances, Specifically dietary patters for ages 19-59 and ages 60 and over. Any and all dietary nutritional oversight reports will be reviewed by Nurse Overseer and Administration to ensure recommendations are followed and implemented. March 1, 2022
Standard #:	22VAC40-73-620-B
Description:	Based on document review and staff interviewed, the facility failed to ensure it took action in response to the recommendations noted in the nutritional oversight report and document such information in the resident?s record. Evidence: 1. On 12-15-21, the inspector inquired of staff #1 the recommendations provided the facility as documented in the January 29, 2021 nutritional report. Staff #1 was informed of the dieticians report that documented forwarding to staff #1, a 5 week, 2 entree/meal menu to staff #1 for menu planning ideas. The requirements for provided full meal and providing sauces, gravies, butter, jellies, etc. as appropriated for the food item on foods for moisture and for extra needed calories. The inspector did not see any of the recommendations from the dietician?s report on the day of the inspection. 2. The inspectors reminded staff #1 and CS-1 of the regulation regarding following up on the recommendations provided to the facility. Staff also informed of the regulation requirement for meals for adults in the facility unless the resident?s physician or other prescriber?s have otherwise written an order for something different. 3. Staff acknowledged receiving a copy of the dietician?s January 2021 review.
Plan of Correction:	8 ounce plastic bowls will be purchased by facility to ensure the amounts served met the guidelines set forth by the USDA. USDA Dietary Guidelines for Americans 2020-2025 printed for staff referencing. Dietary Staff in-serviced on dietary guidelines and the importance of residents receiving daily/weekly allowances, Specifically dietary patters for ages 19-59 and ages 60 and over. Any and all dietary nutritional oversight reports will be reviewed by Nurse Overseer and Administration to ensure recommendations are followed and implemented. March 1, 2022
Standard #:	22VAC40-73-690-G
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure it took action in response to the recommendation noted in the pharmacy review and documented the information in the resident?s record. Evidence: 1. On 12-15-21, resident #3?s pharmacy review completed in August 2021 recommended resident?s Hydrocortisone cream be discontinued. The record did not contain documentation of the facility?s follow-up on the recommendation. 2. CS-1, the individual who completes the Healthcare oversight, was asked who was responsible for ensuring the recommendations of the consults were completed and documented in the resident?s record. CS-1 stated the facility staff should be reviewing the recommendations and providing information to the resident?s physician. 3. Staff #1 acknowledged no action was taken of the pharmacy?s recommendation for the aforementioned resident?s medication.
Plan of Correction:	Nursing staff will be in-serviced by Nurse Overseer on the appropriate actions needed in response to pharmacy overview recommendations. RMA?s will review recommendations and fax appropriate physician, making note on pharmacy review form and/or physician?s order form of recommendations by pharmacy and request physician?s response. February 15, 2022
Standard #:	22VAC40-73-870-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the interior of the building was maintained in good repair and kept clean. Evidence: 1. On 12-15-21 during a tour of the facility with staff #1, the entrance area to the bathtub in room #52 was observed to be cracked and in need of repair. The carpet in bedrooms and foyer area in rooms #29-A, #11, #13, and #21 were observed with heavy dark black stains and in need of cleaning. The vents in room #29 and the nursing station/medication room was observed with heavy coating of grey substance. The refrigerator in room # 29 was observed to have dark brown rusted like stains. The wall in the entrance area to the nursing station/medication room needs painting, the metal area of the wall is exposed. The wood floor in the entrance way of the medication room/nursing station was observed to be cracked and splitting with loose pieces of wood in the area. 2. Staff #1 acknowledged facility conditions observed.
Plan of Correction:	Maintenance Request Form will be available to staff and residents to report repairs needed. Maintenance staff will pick up request forms weekly and complete requests to ensure repairs are done in a timely manner. Carpet in apartments with stains will be cleaned by a profession company. (All carpets will eventually be replaced) March 1, 2022
Standard #:	22VAC40-73-960-C
Description:	Based on observation and staff interviewed, the facility failed to ensure the telephone number for Poison Control Center was posted by the telephone in the medication room/nursing station. Evidence: 1. On 12-15-21, the facility?s pharmacy review dated 7-14-21 documented the poison control phone number was not posted. Staff # 3 was inquired where the telephone listing for emergency was posted. Staff pointed to the bulletin board in the medication room. The Poison control number was not posted and the number could not be located by staff. 2. Staff #3 acknowledged the Poison Control Center number was not posted or available on the day of the inspection.
Plan of Correction:	New Poison Control Center phone numbers labels will be placed on all desk phones throughout the facility to replace the already existing ones that are peeling off. All staff will be in-serviced on the location of important/emergency phone numbers location in the nurse?s station. March 1, 2022
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the first aid kit included all required items. Evidence: 1. On 12-15-21, the first aid kit in medication room/nursing station did not include an assortment of Band-Aids. 2. The first aid kit for the facility van did not include adhesive tape. 3. Staff #2 and CS-1 acknowledged the facility first aid kits did not include all required items.
Plan of Correction:	Request form for items needed to ensure 1st Aid kit is fully stocked will be added to 1st Aid checklist book, so staff may get list of items needed to Assistant Administrator for purchase. January 21, 2022