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. 16, 2023 and May 31, 2023

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 (LI/LA) on 12-16-2022. 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 11-29-2022 and 10-11-2022 regarding allegations in the staffing and resident care and related services (food- staffing- and the building) Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 6 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be 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 at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-150-F
Complaint related:	Yes
Description:	Based on interview, the facility licensed for both residential and assisted living care, the administrator shall serve on a full-time basis as the on-site agent of the licensee and shall be responsible for the day-to day- administration and management of the facility. Evidence: 1. On 12-16-22, during a complaint inspection regarding the administrator not being at the facility, the administrator did not have a schedule of days and/or times at the facility. The administrator acknowledged not being in the country the first week in November 2022. When asked what days the resident was out of the country, the administrator proceeded to look for the days in his phone but did not provide the inspectors with days or times the administrator was not in the United States of America. 2. Staff #2 stated not being in the country November 5, 2022 to November 28, 2022. 3. The administrator?s schedules dated 8-14-22 to 9-25-22 and 9-26-22 to 11-6-22, documented the administrator?s hours. The administrator schedule did not reflect administrator?s presence on a full-time basis as the on-site agent of the licensee. The schedule noted the following hours: 8-14 to 8-21-22 (21 hours (h); 8-22 to 8-28 (30-h); 8-29 to 9-4-22 (16.5 h); 9-5 to 9-11-22 (25 h); 9-12 to 9-18-22 (35 h); 9-19 to 9-25-22 (24 h); 9-26 to 10-2-22 (34.5 h); 10-3 to 10-9-22 (23 h); 10-10 to 10-16-22 (23.5 h); 10-17-to 10-23-22 (31 h); 10-24 to 10-30-22 (16.5 h) and 10-31-11-6-22 (30 h). 4. The facility did not have documentation of who was in charge, and responsible for the day-to day administration in the administrator and assistant administrator?s absence.
Plan of Correction:	The provider did not provide a plan of correction.
Standard #:	22VAC40-73-280-A
Complaint related:	Yes
Description:	Based on documents reviewed and staff interviewed, 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 the resident assessments and individualized service plans. Evidence: 1. On 12-16-22 during a complaint inspection, the direct care staff scheduled provided noted one direct care staff schedule on multiple days and shifts to provide services. The facility census was 33, and has residents assessed at the assisted living level of care requiring assistance with bathing, feeding, incontinent care and transferring. The is one staff to administer the medication for two medication carts for thirty- three residents, twenty-two residents come to the nursing station, the other staff must go to their rooms. The facility was also on fire-watch duties The facility?s vehicle has not been available to transport residents to appointments since the summer of 2022. According to staff interview, the resident?s special medical appointments were rescheduled because there was no vehicle and no transportation driver; (special medical appointments: urology, gastrointestinal, hernia surgery). 2. The direct care staff schedule for 8-14 to 9-24-22 (6a- 2:30 p shift) noted one staff fourteen days and 2p to 10:30p shift noted one staff 10 days. The schedule dated 9-25 to 11-5-22 (6a-2:30 p shift) noted one staff 30 days and 2- to 10:30p shift noted one staff 11 days. The schedule dated 11-6 to 12-17-22 (6a-2:30p shift) noted one staff 32 days and 2p to 10:30p shift noted one staff fourteen days.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-290-A
Complaint related:	No
Description:	Based on documents provided by and staff interviewed, the facility failed to ensure the written work schedule indicated whoever is in charge at any given time. Evidence: 1. The facility staff schedules provided by staff #2 (administrator, housekeeping, registered medication aide, direct care staff and dietary) did not indicate who was in charge at any given time.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 was dated and posted in an area conspicuous to residents. Evidence: 1. On 12-16-22, during the inspector and licensing administrator?s tour of the facility, the menu for the current week was not posted. Upon posting the menu did not document the substitution of sausage for ham for the breakfast meal observed. 2. Staff # 3 acknowledged the menu was not posted and the substitution not documented.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-D
Complaint related:	No
Description:	Based on interview, the facility failed to the building was kept free of infestations of insects and vermin. The ground shall be kept free of their breeding places. Evidence: 1. On 12-16-22, interview with staff #4, regarding an allegation of scabies, the staff stated no residents had scabies. Staff #4 stated room 32 and 10 were sprayed for bed bugs. A request for the facility?s documentation of pest control report on 12-16-22 was not provided with requested documents. A second request was made on 12-22-22 without success.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-E
Complaint related:	No
Description:	Based on observation and staff interviewed, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition. Evidence: 1.On 12-26-22 during a tour of the facility, the female, public bathroom located across from the nursing station was not working. Staff stated the bathroom had been out of order for at least a week.
Plan of Correction:	Not available online. Contact Inspector for more information.