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: March 28, 2022 and March 29, 2022

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 monitoring inspection was conducted on 3-28-22 and 3-29-22. The facility census was 40. A tour of the facility was conducted, a medication pass observation was conducted, review of staff and residents records, interviews with staff and residents, breakfast and lunch meal observed, emergency preparedness information observed. A review of violations were reviewed with staff throughout the inspection process. An exit was conducted on 3-29-22 with the assistant to the Administrator and nurse consultant. The acknowledgement form was sent via email to the Administrator. 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 4-22-22 If you have any questions, contact your licensing inspector at (757) 439-6815.

Violations:

Standard #:	22VAC40-73-40-B
Description:	Based on observation and staff interviewed, the facility failed to ensure that the current license was posted in the facility in a place conspicuous to the residents and the public. Evidence: 1. On 3-28-22, the licensed posted in the facility was an annual license which expired 2-28-22. The current license is a Provisional license and expires 8-28-22. 2. Staff #1 and #2 acknowledged during the course of the inspection process the facility did not have the current license posted.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-210-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure direct care staff who are certified nurse aides shall attend at least 12 hours of annual training. Evidence: 1. Staff #3?s record did not include documentation of 12 hours of annual training. Staff?s record included 9 hours of training (5 hours infection control and 4 hours of medication refreshers). Staff?s date of hire document as 8-13-07. 2. Staff #2 and CS-1 acknowledged the aforementioned staff?s record did not have documentation of the required 12 hours of annual training.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-290-A
Description:	The facility failed to ensure it maintained a written work schedule for all staff that 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 3-28-22 a request was made for the staff schedule for each department and to highlight any new staff since the facility?s last inspection per the ?What your inspector needs from you today?, form. 2. The facility did not have schedules for the following department staff, administrator and assistant to administrator, housekeeping, activity, transportation and dietary. 3. The direct care staff schedule did not include the names of agency staff documented on the schedule, it simply stated ?Agency?. 4. Staff #1 and #2 acknowledged during course of inspection process, the facility did not have schedules for the aforementioned departments.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions or care needs for one of six residents. Evidence: 1. Resident #2?s March 2022 medication administration record (MAR) documented resident prescribed Trazadone, the physician order summary (POS) dated 3-15-22 also documented resident?s Trazadone. The resident?s record did not include a signed and dated psychotropic treatment plan. Resident also prescribed Risperidone, treatment plan did not include a date the plan was signed. 2. Staff #2 and CS-1 acknowledged during exit meeting the aforementioned resident?s record did not contain a treatment plan for prescribed psychotropic medication.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for four of six residents. Evidence: 1. Resident #1?s uniformed assessment instrument (UAI) dated 7-2-21 documented bathing need as mechanical help/physical assistance. The individualized service plan (ISP) dated 7-2-21 documented mechanical help and Supervision (grab-bar and cues/ reminders). Wheeling need assessed as not performed; the ISP did not include this assessed need. 2. Resident #3?s UAI dated 4-7-21 documented wheeling need as not performed. This need was not included on the ISP dated 4-7-21. 3. Resident #4?s UAI dated 11-19-21 documented wheeling need as not performed. This need was not included on the ISP dated 11-30-21. 4. Resident #6?s UAI dated 6-28-21 documented bathing need as mechanical help/physical assistance. The ISP dated 3-1-22 mechanical help/ supervision (cueing needed). Wheeling need documented as not performed. This need was not included on the ISP dated 3-1-22. 5. Staff #2 and CS-1 acknowledged during the exit meeting the aforementioned residents? records did not include all assessed needs.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-640-A
Description:	Based on observation and staff interviewed, the facility failed to ensure that methods to prevent the use of outdated, damaged, or contaminated medications was conducted. Evidence: 1. On 2-29-22, during a check of the medication cart with staff #4, resident #1?s Permethrin cream had an expiration date of 3-4-22. 2. Staff #4 and CS-1 acknowledged the aforementioned medication should not have been on the cart due to it being expired.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-660-A
Description:	Based on observation and staff interviewed, the facility failed to ensure medications storage area was locked. Evidence: 1. On 2-28-22, staff #---- was administering eye-drops to a resident at the window. The inspector walked into the medication room and noticed the medication cart located on the right wall of the medication room was not locked. The staff was at the window behind the wall administering the eye-drop and talking with CS-2. 2. On 2-29-22, during a check of the medication cart with staff #3, it was observed that the refrigerated medications were not stored in a locked storage room. The refrigerator with residents? medications were stored in the staff breakroom down the hallway from the medication room. This room is not locked and the door was open. 3. Staff #3 and CS-1 acknowledged during the course of the inspection that medication cart was not locked and refrigerated medications were not stored in a locked room.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-B
Description:	Based on observation and staff interviewed, the facility failed to ensure medication shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. Evidence: 1. On 2-28-22 at approximately 5:05 p.m., the licensing inspector was in the medication room and noticed the medication cart was unlocked. Staff #8 finished administering a resident?s eye-drops and came back to the medication cart. Staff #8 opened the top portion of the medication cart and a container with pre-poured medications was observed. Staff stated it was resident #7?s Clozaril that was crushed and mixed for administration. Other medications for resident #7 that were observed pre-poured included Klonopin, Fibercon and Ibuprofen. 2. Staff #8 acknowledged preparing the medications beforehand to administer later to resident #7 on 2-28-22.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 2-29-22, the pharmacy review dated 2-15-22 document recommendations for the resident #1, #2, #3 and #5. The recommendation actions taken were not completed. 2. CS-1 acknowledged no action was taken of the pharmacy?s recommendation for the aforementioned resident?s medications.
Plan of Correction:	Not available online. Contact Inspector for more information.