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: May 4, 2023 and May 31, 2023

Complaint Related: No

Areas Reviewed:

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

Comments:

Type of inspection: Monitoring An unannounced monitoring inspection conducted by two inspectors (LA/LI) on 5-4/2023 (Ar 10:50 a.m/dep 4:40 p.m.) The facility census was 32. A tour of the facility was conducted, the lunch meal was observed, staff and residents? records reviewed. The administrator was not present but arrived later and signed the Acknowledgement Form. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A final exit meeting will be scheduled. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-50-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it prepared and provide a statement to the prospective resident and the legal representative, if any, that discloses information about the facility. Documentation of the acknowledgement should be in the resident?s record. Evidence: 1. On 5-4-23, resident #1?s record did not have written documentation of having received the facility?s disclosure document. The resident?s date of admit noted as 1-21-23.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-140-E
Description:	Based on record review and staff interviewed, the facility failed to ensure administrators who supervise medication aides shall be required to annually have four hours of training in medication administration specific to the facility population or a refresher course in medication administration offered by the Virginia Board of Nursing approved program. Evidence: 1. On 5-4-23, staff #1?s record did not have documentation of the medication refresher course. Staff #1 supervises the registered medication aides in the facility. Staff?s date of hire is unclear, 1-5 2005 or 1999.
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 staff in a facility licensed for both residential and assisted living care, staff shall attend at least 18 hours of training annually. Evidence: 1. On 5-4-23, staff #1?s record noted only 12 hours of dementia training (3-2-22). The record did not include the required infection control training.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-260-A
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure staff maintained current certification in first aid. Evidence: 1. Staff #1 did not have documentation of a current certification in first aid.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-310-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a documented interview between the administrator or a designee responsible for admission and retention decision, the individual and legal representative, if any. Evidence: 1. On 5-4-23, resident #2?s record did not have documentation of an interview and mental health assessment for admissions.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-310-D
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it provided written assurance to the resident and the legal representative, if any, that it had the appropriate license to meet the resident?s care needs at the time of admission. Evidence: 1. On 5-4-23, resident #1?s record did not have documentation of having received and signed the facility?s acknowledgement of being provided written assurance it had the appropriate license to meet the resident?s need at the time of admission. The resident?s date of admit was noted as 1-21-23.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-410-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s record included written acknowledgement of orientation for new residents. Evidence: 1. On 5-4-23, resident #1?s orientation document in the record was not signed and dated by resident or legal representative. Resident?s date of admit noted as 1-21-23. 2. Resident #2?s orientation document in record was incomplete and not signed by resident, legal representative and neither by facility representative. Resident?s date of admit noted as 1-15-23.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-D
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that for private pay individuals the assisted living facility shall ensure that uniform assessment instrument (UAI) was in compliance as required by 22VAC30-110. Evidence: 1. On 5-4-23, resident #2?s uniform assessment instrument (UAI) dated 1-6-23 was not completed per the requirements. The document was also not signed and dated by the assessor and the facility reviewer. The resident?s date of admission was noted as 1-5-23.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-B
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was completed by the licensee, administrator, or the designee who has successfully completed the department-approved individualized service plan (ISP) training, provided by a licensed health care professional practicing within the scope of his profession. Evidence: 1. On 5-4-23, resident #1?s individualized service plan (ISP) dated 1-24-23 and 2-24-23 was developed by staff #2. The ISP should be completed by the licensee, administrator or designee who has successfully completed the department approved individualized service plan (ISP) training provided by a licensed healthcare professional practicing within the scope of her profession. Staff #2 did not have ISP training at the time of the ISP development. 2. Resident #2?s ISP dated 1-5-23 and 2-5-23 was completed by staff #2, a person not authorized to complete the ISP.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-470-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure, either directly or indirectly, that the health care service needs of residents are met. Evidence: 1. On 5-4-23, resident #1?s record included prescriber?s order dated 2-15-23 for ? PT/OT evaluate?. The resident?s record did not include documentation of service being conducted and the services were not documented on the resident?s ISP dated 2-24-23.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-520-I
Description:	Based on observation and staff interviewed, the facility failed to ensure the current month?s activity schedule shall be posted in a conspicuous location in the facility or otherwise be available to residents and their families. Evidence: 1. On 5-4-23, during a tour of the facility, the activity calendar posted on the bulletin board across from staff breakroom was for the month of April 2023. 2. Staff #3 acknowledged the current month?s calendar was not posted on 5-4-23.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-550-G
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities was reviewed annually with each staff person with written acknowledgement of having been informed, which shall include the date of the review and shall be filed in staff person?s record. Evidence: 1. Staff #1?s record did not have documentation of review of resident?s rights and responsibilities.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-610-C
Description:	Based on observations and staff interviewed, the facility failed to ensure the servings of the food listed on the menu 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 residents. Evidence: 1. On 5-4-23, during the lunch meal observation, the residents were served coleslaw and peaches in 3.25 fluid oz cups (96.1ml), the same cup used to serve the condiments (ketchup and mayonnaise). The coleslaw cups were half-full. Based on observations, staff #5 was asked if the dietary manual was available, so that the correct serving amount could be determined. The residents were served three small fish sticks, french fries, and 1-2 sliced tomatoes and lettuce. 2. The facility nutritional report dated 3-28-23 and 4-4-23 documented the facility to use the diet manual provided for assist with menu and meal preparation and a menu planner checklist provided to staff #2.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-860-I
Description:	Based on observations and staff interviewed, the facility failed to ensure that it stored cleaning supplies and other hazardous materials in a locked area. Evidence: 1. On 5-4-23 during a tour of the facility with staff #2, cleaning products- washing liquids were located in the unlocked laundry room near the nursing station. In the common area, the future dining room for the safe, secure unit, high traffic floor polish was located in the common bathroom and floor cleaner was also located in the dining area near the closet.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-E
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 5-4-23 during a tour of the facility, the secure sealant to the pipe/tubing for the hot water heater locater in the laundry room near the nursing station was coming apart from the ceiling. The metal/stainless steel was not sealed/flushed and grounded to the ceiling. The right corner of the counter in room #47 is missing portion of the formica and the door is missing from the cabinet above the right side of the sink, the hood contains brown colored substance. The toilet in the dining area on the safe, secure unit was missing the top to the toilet seat and the shower was missing the shower head. The bathtub in room #17 is in need of repair- resurfacing. The refrigerator in the food storage room near the administrative office was in need of cleaning, brown liquid substance on shelves.
Plan of Correction:	Not available online. Contact Inspector for more information.