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: July 20, 2022 , July 28, 2022 and Aug. 25, 2022

Complaint Related: Yes

Areas Reviewed:

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

Comments:

Type of inspection: Complaint An unannounced complaint inspection conducted by two inspectors (ERO/PLO) on 7-20-22. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 7-11-22 regarding allegations in the staffing and resident care and related services (food- medication- wandering/elopement) . Number of residents present at the facility at the beginning of the inspection: Facility census was 35 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings on August 15, 2022 and August 22, 2022 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 at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on record reviewed and staff interviewed the facility failed to report to the 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 7-20-22 during a complaint inspection regarding resident #1?s elopement from the facility and found in the community, interviews with staff members and collateral interview confirmed the resident was not present in the facility for a period of time and was returned by someone from the community. Following knowledge of the resident?s elopement from the facility, the resident?s individualized service plan (ISP) was updated on 5-2-22 for staff to conduct 30 minute checks for the resident?s safety. Prior to this event, the resident?s record documented on 5-21-21, concerns regarding the resident wandering outside the facility. The concern was also presented to the resident?s treating physician for evaluation of medication. The resident?s progress notes documented multiple occasions of resident being observed outside of the facility without staff from May 2021 to April 17, 2023. The uniform assessment instrument (UAI) dated 27-22 assessed the resident as a wandering greater than weekly. The ISP dated 2-11-22 documented staff to monitor resident because of wandering behavior. The resident?s record did not document the recent elopement. Interviews with facility staff stated being aware of the elopement incident but did not document incident in resident?s record. The facility also did not complete an incident report following knowledge of the resident leaving the facility and being returned by a person from the community. Staff #3, #4. #5 and #9 were interviewed and acknowledged resident left facility and was returned by an individual from the community. 2. Resident #1?s record documented additional incidents that were not reported to the licensing office. On 4-16-22 (7 am), staff documented ?resident found on floor...left knee, left hand as well as face had bruising, scratch on left shoulder as well, sent out to hospital. Resident?s discharge summary from the hospital documented: contusion of face (left side) and contusion of dorsum of hand (left hand). The resident?s record also included a ?resident incident/accident form documenting resident found face down on the floor with both knees swollen...bruises on the face, left side and hand, scratches on left shoulder. 3. Resident?s discharge summary from local hospital on 4-27-22, documented head injury with staples received to be removed in 7 days by primary care provider, clean area of the wound twice daily with soap water, may apply a small amount of bacitracin for the next 2-3 days after cleaning. Reason for visit: fall/ head injury. Diagnoses: closed head injury/scalp laceration. Nurse?s notes on 4-30-22 at (7 p.m.) documented CS-1 did resident #1?s wound care on her head. The record also included a transfer form dated 4-27-22 documenting, ?resident has a dash on top of resident?s head?. 4. On 8-15-22, staff acknowledged incident reports were not reported for the aforementioned resident as required.
Plan of Correction:	Administration acknowledges procedural failures due to change in staff designated to make reports. Procedural changes implemented whereby all incidents will be filtered through new assistant to the Administrator to ensure timely reports are made. All staff has been informed of the requirement to report all activities defined as reportable incidents to the assistant to the administrator immediately. Assistant assumes responsibility with the administrator to ensure all incidents are reported within 24 hours of occurrence. Resident undergoing review and evaluation for an update of plan of care or proper placement. In addition to disciplinary actions, staff undergoing additional training and evaluations. Person Responsible: Administrator, Assistant to Administrator, Agency Contracted Nurse, Consultant
Standard #:	22VAC40-73-280-A
Complaint related:	No
Description:	Based on documents reviewed and interviews, 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 psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with the regulation. Evidence: 1. On 7-20-22 during a complaint inspection, the inspector observed two staff person in the facility. Upon interviews with staff #7 and #8, neither staff was trained to administer medications. According to staff, the medication room was off limits. If someone needed something staff would have to contact staff #2. 2. Resident #2 interviewed and stated not receiving morning medications because there is no one in the facility to give out medications. The resident?s July 2022 medication administration record (MAR) included the following medications to be administered at 04:00 a.m.: (1) Cyclobenzaprine,( 2) Gabapentin and (3) Ibuprofen. The resident did not receive medication on July 20, 2022, when the inspector arrived, there was no one in the facility authorized to administer medications. 3. The facility?s July 3 to August 13, 2022 registered medication aide (RMA) schedule did not have a staff scheduled on the 10:00 p.m. to 6:30 a.m. shift on 7-5-22, 7-9-22 and 7-19-22.
Plan of Correction:	The administration acknowledges an inadequate number of Registered Medication Aides and currently has four (4) staff in training to complete the Medication Aide training class during the week of August 29, 2022. The facility has hired one (1) trained Registered Medication Aide who is licensed as an RMA. To prevent future violations of this standard, the administration will continuously advertise for Registered Medication Aides as well as obtain an additional training vendor to enhance the timeliness of training completion of those hired. Once the four (4) currently hired staff is provisionally licensed, the facility, with oversight of contract nurse, shall be able to staff time slots and prevent any missed medications. In addition, the resident with 4:00 AM administration of medication was changed to 6:00 AM medication scheduled. Person Responsible: Administrator and Assistant to Administrator, Agency Contracted Nurse
Standard #:	22VAC40-73-320-B
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a risk assessment for tuberculosis (TB) was completed annually for each 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 7-20-22 during a complaint inspection, resident #2?s TB document was dated 6-8-21, resident?s date of admission was documented as 8-15-17. 2. On 8-15-22, staff acknowledged the aforementioned resident?s TB was not updated.
Plan of Correction:	The assistant to the Administrator and agency Contracted Nurse are addressing TB Risk Assessments for resident #2. To prevent future violations of this standard, the Administrator, Assistant to the Administrator an Agency Contracted Nurse and an assistant are reviewing 100% of resident files to identify those in need of annual risk assessment. Person Responsible: Administrator, Assistant to Administrator, Agency Contracted Nurse
Standard #:	22VAC40-73-325-A
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s fall risk rating shall be reviewed and updated when the condition of the resident changes and after a fall. Evidence: 1. On 7-20-22 during a complaint inspection, resident #1?s nurse?s notes dated 4-16-22 (7 a.m.), documented resident fell and was sent to the hospital. The record also included a discharge summary date 4-27-22 from a local hospital, documenting resident seen and treated for a fall. The risk rating in the record on 7-20-22 was dated 2-11?22. 2. On 8-15-22, staff acknowledged the fall risk rating was not completed for the aforementioned resident following each fall.
Plan of Correction:	Agency Contracted Nurse, Activities Coordinator, and Assistant to Administrator are reviewing records of resident #1 to review falls and the need for updated risk ratings. Agency Contracted Nurse will update risk assessment on residents requiring update. To prevent future violations of this standard, the staff will notify assistant to administrator of all falls immediately. Assistant to administrator will submit incident reports to DSS Licensing and meet with agency Contracted Nurse to have updated risk rating completed. Agency Contracted Nurse will complete an updated risk rating within 72 hours of fall. All falls will be reviewed by the Administrator, Assistant to Administrator, Agency Contracted Nurse, Activities Coordinator, and RMAs weekly. Weekly reviews will be documented. Person Responsible: Agency Contracted Nurse, Activities Coordinator and Assistant to Administrator
Standard #:	22VAC40-73-440-D
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure for a private pay individual, the Uniformed Assessment Instrument (UAI) is completed as required 22VAC30-110. Evidence: 1. On 7-20-22, during a complaint inspection, resident #1?s UAI dated 2-7-22 was not signed by the designee or administrator. 2. On 8-15-22, staff acknowledged the aforementioned UAI was not signed and dated as required.
Plan of Correction:	The nurse and Assistant to Administrator are addressing the update of UAI for residents #2 and 6. To prevent future violations of this standard, the Administrator, Assistant to Administrator, and Agency Contracted Nurse are reviewing 100% of all resident records to assess the need for updated UAI. A monthly log of UAI updates needed will be maintained by the Assistant to Administrator and Agency Contracted Nurse to ensure UAIs are updated timely. In addition, the facility is training two additional staff to complete UAIs to assist nurse in meeting update deadlines. Person Responsible: Administrator, Assistant to Administrator, Agency Contracted Nurse, Activities Coordinator and RMA
Standard #:	22VAC40-73-440-H
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure an annual reassessment or reassessment due to a significant change is completed using the UAI, to determine whether a resident?s needs can continue to be met at the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: 1. On 7-20-22 during a complaint inspection, resident #2?s UAI was dated 8-18-20. The resident?s date of admit was documented 8-15-17. 2. On 8-15-22, staff acknowledged the aforementioned resident?s UAI was not completed annually as required.
Plan of Correction:	The nurse and Assistant to Administrator are addressing the update of UAI for resident #2. To prevent future violations of this standard, the Administrator, Assistant to Administrator and Agency Contracted Nurse are reviewing 100% of all resident records to assess need for updated UAI. A monthly log of UAI updates needed will be maintained by Assistant to Administrator and Agency Contracted Nurse to ensure UAIs are updated timely. In addition, the facility is training two additional staff to complete UAIs to assist nurse in meeting update deadlines. Person Responsible: Administrator, Assistant to Administrator and Agency Contracted Nurse, Activities Coordinator and RMA
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed as the condition of the resident changes. Evidence: 1. On 7-20-22, during a complaint inspection, resident #2?s individualized service plan (ISP) was dated and signed by the developer on 8-18-20. The end/review date was documented as 8-18-21. 2. On 8-15-22, staff acknowledged the aforementioned resident?s ISP was not updated as required.
Plan of Correction:	Agency Contracted Nurse is reviewing resident #s 2 treatment plan for update. A treatment plan will be appropriately updated after consultation with resident?s treatment practitioner. To prevent future violations of this standard, the administrator, assistant to the administrator, Agency Contracted Nurse, Activities Coordinator and RMAs are reviewing 100% of all resident?s records to identify those requiring updated treatment plans. The review will be documented and plans requiring updates will be accomplished. Any resident who discharges from or leaves the facility for an extended period of time will have an updated treatment plan completed upon reentry. In addition, the Administrator, Assistant to Administrator, Agency Contracted Nurse, Activities Coordinator and RMAs will meet weekly to review residents requiring updated treatment plans. Agency Contracted Nurse will ensure updated plans are accomplished. Weekly reviews will be documented. Person Responsible: Administrator, Assistant to Administrator, Agency Contracted Nurse, Activities Coordinator and RMAs
Standard #:	22VAC40-73-680-C
Complaint related:	No
Description:	Based on documents reviewed and staff interviewed, the facility to ensure medications shall be administered not earlier than one hour before and not later than on hour after the facility?s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: 1. On 7-20-22, resident #3?s July 2022 medication administration record (MAR) documented resident did not receive the following medications in accordance with the facility dosing scheduled during the month of July 2022: (1) Artificial tears, (2) Aspirin 81 mg, (3) Atorvastatin, (4) Cyclobenzaprine, (5) Famotidine, (6) Gabapentin, (7) Ibuprofen, (8) Levetiracetam, (9) Metoprolol Tartrate, (10) Omeprazole, (11) One-Tab daily w/minerals, (12) Phenobarbitol and (13) Zonisamide 2. Resident #4 did not receive the following medication in accordance with the facility?s dosing scheduled during the month of July 2022: (1)Ascorbic acid, (2) Carvedilol, (3 Cetirizine, (4) Docusate Sod/Senna, (5) Dutasteride, (6) Finasteride, (7) Levetiracetam, (8) Lorazepam, (9) Morphine Sulfate, (10) Multivitamin, (11) Rosuvastatin, (12) Sertraline, (13) Tamulosin, (14) Temazepam, (15) Tizanidine, (16) Vitamin B12 and (17) Xarelto.
Plan of Correction:	Agency Contracted Nurse is in the process of conducting a quarterly medication review to assess medication administrations for each resident. These reviews are to be done weekly and staffing shortage and requirement of Agency Contracted Nurse to conduct training of new hires has negatively impacted the reviews. However, nurse will complete a review of all resident MARs and will conduct refresher training/review with identified RMA as well as all RMAs to reinforce following medication administration protocols. Disciplinary action will be noted in staff record to enforce learning/compliance with any future non-compliances. Person Responsible: Agency Contracted Nurse and Administrator