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: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

Licensing inspector conducted an on-site complaint inspection on 3-28-22 and 3-29-22 (ar 07:30 a.m/dep 6:00 pm on day 1 of inspection. The Acknowledgement of Inspection form was sent via electronic email for both days of inspection. A complaint was received by VDSS Division of Licensing on 3-20-22 regarding allegations in the resident food and meal. There were 40 residents present on 3-28-22, day 1 of the complaint inspection. A tour of the dining area, kitchen and food storage areas were conducted. Resident interviews were conducted, residents? preference to speak if names would not be provided. There were six staff member interviews conducted Observation of the breakfast, lunch and dinner meals were conducted on day 1, 3-28-22. Facility toiletries were observed as this was a concern during interview with a resident. An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Willie Barnes Licensing Inspector at 757-439-6815 or by email willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-610-B
Complaint related:	No
Description:	Based on observation and staff and resident interviews, the facility failed to ensure the menus and snacks for the current week included substitutions or additions to the posted menu. Evidence: 1. On 3-28-22, the dinner menu for 3-27-22 documented lemon herb linguine, mixed vegetables, garlic bread and soup or salad. Interview with residents and staff #3, the residents? were served bar-b-que ribs, yams, collard greens, and corn muffins. This meal was provided by staff #3 from personal supply. Menu did not reflect this change. 2. On 3-28-22, the breakfast menu documented biscuits and gravy, scrambled eggs, fresh fruit, ? cup of oatmeal or ? cup dry cereal. Based on observation, no eggs or fresh fruit was served. The menu did not reflect the changes, first seating received bacon and second seating served sausage patties because there was not enough of either to serve the census of 40. No eggs were served at breakfast, this change was not on the breakfast menu posted. 3. The menu for lunch on 3-28-22 noted turkey and Swiss sandwich, onion rings and mixed fruit. The inspector observed turkey and American cheese sandwich, fruit cocktail, potato chips and ? sliced pickle and tostados chips served at second seating .These changes were not documented on the lunch menu. 4. Dinner menu listed the following items: BBQ pork loin, mashed potatoes, collard greens, soup or salad, dessert, coffee-tea-lemonade. The following was observed served: BBQ pork loin, baked beans, strawberry cake with vanilla frosting, bread sticks, coffee. The changes were not documented on the lunch menu.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-610-C
Complaint related:	Yes
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: On 3-28-22 during a complaint inspection regarding the facility not having food, the morning meal was observed. The cooking staff did not have sufficient amount of food for all residents. The facility census on was 40. The menu listed the following items for breakfast: biscuit and gravy, scrambled eggs, fresh fruit, 1/2 cup oatmeal or ? cup dry cereal, coffee-milk-juice. The first seaters were served: bacon, some received oatmeal and some received biscuit and gravy. The second seaters were served biscuit and gravy, sausage patties and banana. There was not enough biscuit and gravy for everyone during the second seating. There was only enough bananas for the second seaters. According to dietary staff, this has been the situation for about month. There is not always enough food for everyone to receive what is on the menu or when the residents request seconds. This was also confirmed during interviews with residents. 2. The eggs in the refrigerator could not be served because it was needed for the egg and cheese omelet for Tuesday, 3-29-22?s meals; egg and cheese omelet and egg salad sandwich for lunch. 3. A check of the food supply in the kitchen/pantry refrigerators and storage area determined there was a lack of food within the facility for 40 residents to receive a nutritious well-balanced meal (breakfast, lunch and dinner) and provide lunch meals for the residents who took lunch to their day program. 4. The residents were not provided seconds were asked due to the insufficient amount and availability of items served. 5. Interviews with residents and staff stated, a staff member personally brought food to the facility and prepared it for the residents for Sunday, 3-27-22?s dinner meal. According to interviews and information on the menu, the residents stated the facility have not had enough food since a staff member left about a month ago. 6. The facility have a monthly menu posted, however, the items on the menu are not available and what is posted is not being provided to the residents during mealtimes. A well- balanced meal as required was not observed served on 3-28-22.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-610-E
Complaint related:	No
Description:	Based on interviews, the facility failed to ensure a copy of a diet manual containing acceptable practices and standards of nutrition was kept current and readily available to personnel responsible for food preparation. Evidence: 1. On 3-28-22, the lead cook for the morning was asked if there was a copy of the facility?s diet manual. The staff was not able to locate the required diet manual. 2. Staff was asked what reference was used to make substitutions when an item on the menu was not available or preparation for items for residents who were diabetic. Staff stated using whatever was on hand or not giving a resident an item if their diet stated they could not have what was being served.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-980-G
Complaint related:	Yes
Description:	Based on observation and staff interviewed, the facility failed to ensure the availability of a 96-hour of supply of emergency food and drinking water. At least 48 hours of the supply must be on site at any given time, of which the facility?s rotating stock may be used. Evidence: 1. On 3-28-22 during a complaint regarding facility?s lack of food, staff was asked why not use the emergency food supply to address the food limitation in the pantry. Staff stated there was no real emergency food. A check of the facility food storage determined there was limited emergency food available. The pantry contained 2-#10 cans of yams, 6- #10 cans of corn, 4-#10 cans of green beans, 1-#10 can of black eyed peas, 4 #-10 cans of beets, 3- 15 ounce cans of chicken soup and 3 cans of tuna (66.5 oz.). There was also 4 (42 ounce) container of oatmeal, 1- 30 ounce container of creamy peanut butter and 1- 4 pound container of peanut butter, 9 loaves of bread, and 2 boxes - 17.6 ounces of corn flakes. There also other condiment items available (ketchup, mustard, salad dressings,) 2.On 3-29-2 2, staff #1 acknowledged the facility did not have 48 hour of emergency food stored on hand.
Plan of Correction:	Not available online. Contact Inspector for more information.