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: June 30, 2023 , July 13, 2023 and July 24, 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 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring An on-site monitoring inspection was conducted on 6-30-23 (AR 09:15/ Dep 3:25 P. The facility census was 32. The administrator was not present but arrive later during the inspection process. A tour of the facility was conducted, medication pass observed, lunch meal observed, staff and resident records reviewed. An exit meeting was conducted with the facility consultant and the administrator signed the Acknowledgment Form The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 #:	22VAC40-73-120-A
Description:	Based on interview and record reviewed, the facility failed to ensure the orientation and training required in 22VAC40-73-120-B and C of the regulation occurred within the first seven working days of employment. Until this orientation and training is completed, the staff person may only assume job responsibilities if under the sight supervisions of a trained direct care staff person or administrator. Evidence: 1. On 6-30-23, staff #6 and #7 record did not have documentation of orientation and training required per the regulation. Staff #6 date of hire noted as 6-5-23 and #7 date if hire noted as 6-19-23.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-200-E
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the facility had a written plan for supervision of direct care staff who have not yet met the requirements as allowed for in (22VAC40-730-C) for direct care qualifications. Evidence: 1. On 6-30-23, staff #5 and #9 did not have documentation of qualifications to provide direct care services to residents. 2. Staff #9 stated not have documentation of paid work or volunteer work with adults who are aged, infirm or disabled. Staff #9?s record did not have documentation or certification of direct care training. Staff observed spoon-feeding a resident during the lunch meal on 6-30-23. 3. Staff #5 stated working with adults in another state but did not have certifications of prior training in the record.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-250-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the staff?s personal record include verification that the staff person had received a copy of the current job description. Evidence: 1. On 6-30-23, staff #6, #7 and #8 did not have a signed and dated copy verifying receipt of a job description.
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, prior to admission the assisted living facility, the administrator provided written assurance to the resident that the facility has the appropriate license to meet the care needs at the time of admission. A signed copy by the resident and or legal representative shall be kept in the resident?s record. Evidence: 1. On 6-30-23, resident #1?s record did not have documentation of the written assurance. The resident?s date of admit was noted as 1-5-23. 2. Resident #2?s record did not have documentation of the written assurance. The resident?s date of admit was noted as 6-8-23. 3. Resident #3?s record did not have documentation of the written assurance. The resident?s first date of trial visit (respite stay) was noted as 1-25-23.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s physical examination and risk assessment was completed prior to admission. Evidence: 1. On 6-30-23, resident #3?s physical examination was dated 10-4-22 and the tuberculosis (TB) risk assessment was dated 3-28-23. The resident?s first day of stay in the facility was dated 1-25-23. The resident is on trial visit stays from a local mental health facility. 2. Resident #1?s admitting physical was dated 11-30-22. The resident?s date of admit was noted as 1-5-23. 3. Resident #2?s TB assessment was dated 4-18-23. The resident?s date of admit was noted as 6-8-23.
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 acknowledgment of having received orientation to the facility?s emergency response procedures, mealtimes, and use of the call system (signaling device). Evidence: 1. On 6-30-23, resident #1?s record did not have documentation of orientation to the facility. The resident?s date of admit noted as 1-5-23. 2. Resident #2?s record did not have documentation of orientation to the facility. The resident?s date of admit noted as 6-8-23. 3. Resident #3?s record did not have documentation of orientation to the facility. The resident?s first date of trial visit (respite stay) was noted as 1-25-23.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-E
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure for public pay individuals, the uniform assessment instrument (UAI) was completed by the case manager or qualified assessor. Evidence: 1. On 6-30-23, resident #3?s record did not have documentation of a completed UAI. The resident record noted resident is being provided trial visit (respite) services. The resident?s record noted the resident stay is 48 hours per visit.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the preliminary plan was signed and dated by the licensee, administrator, or his designee, and by the resident or legal representative. Evidence: 1. On 6-30-23, resident #2?s preliminary plan of care in the record was not signed and dated by the resident and/or legal representative. The resident?s date of admit was noted as 6-8-23.
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 that there was an individualized service plan (ISP) for a resident. Evidence: 1. On 6-30-23, resident #3?s record did not have a signed and dated ISP with assessed needs. The record noted the resident have been completing trial visits (respite services) from a local mental health facility. The record noted services (trail visits) began on 1-25-23. 2. Resident #1?s uniform assessment instrument (UAI) dated 2-7-23 noted bathing assessed as human help/physical assistance. The ISP dated 2-5-23 noted resident uses a shower chair during bathing time. Toileting assessed as human help/supervision. The ISP noted resident uses the grab-bars during toileting. Transfer is not noted on the UAI. The ISP noted resident uses arms or chairs/ grab-bars and staff provides supervision. Bowel is assessed as independent. The ISP noted staff provides supervision. The record also noted physical/occupational /speech evaluation order dated 1-12-23. This information was not documented on the ISP.
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 that the activity noted on the schedule was provided. Evidence: 1. On 6-30-23, the activity calendar posted noted, ?Table Volleyball? scheduled for 9:30 a.m. There was no activity or substitution of an activity provided to the residents present on the morning of 6-30-23.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-560-I
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a current picture of a resident was readily available for identification purposes or, if the resident refuses to consent to a picture, there shall be a narrative physical description, which is annually updated and maintained in the resident's file. Evidence: 1. On 6-30-23, resident #3?s record did not have a current picture of identification in the record. The record also did not include a narrative physical description of the resident. The resident trial visit (respite stay) first day of stay was noted as 1-25-23.
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 the furnishings, fixtures, and equipment shall be kept clean and in good repair and condition. Evidence: 1. On 6-30-23, the bottom kitchen shelf was observed with clear plastic with heavy soiled brown substance. There were food and serving items on this plastic sheet. 2. The ceiling area where the camera is in the kitchen is loose and not flushed and grounded to the ceiling. 3. The wall behind the hand sink area sheet rock is missing. The drainpipe underneath the hand sink is not connected. There is a bucket underneath the sink to catch the water. Staff stated the floor area is sometimes flood from the water that is released from the disconnected drainpipe. 4. Staff #3 acknowledged the areas of the kitchen was not maintained in good repair. The area was also observed by consultant #1 on 6-30-23.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-880-A
Description:	Based on interview, the facility failed to ensure at least one movable thermometer was available in the building for measuring temperature in individual rooms that do not have a fixed thermostat that shows the temperature in the room. Evidence: 1. On 6-30-23, the Air Conditioning (Cooling) unit was not operational in all areas of the facility. The facility staff was asked if there was a moveable thermometer to check the temperature of the rooms and common areas. Staff #3 stated that facility did not have a movable thermometer. The staff was asked if there was a meat thermometer or water temperature thermometer available. The staff response was no.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-880-C
Description:	Based on observation and staff interviewed, the facility failed to ensure the air conditioning unit was operational throughout the facility. Evidence: 1. On 6-30-23, upon entering the facility kitchen, the backdoor was observed to be propped open with a chair. Staff #3 stated the AC did not work. 2. The front entrance door was also observed propped open when the inspectors arrived at 09:15 a.m. The front entrance/common area did not have AC working. 3. On 6-30-23, staff #1 stated the unit was not working on 6-23-23. There are 6 total units, and 4 units were working. Staff stated, ?the extractor was not sufficient in refrigeration room, this has to be changed, 1 unit needed to be repaired and 2 units needed to be replaced?. 4. On 7-13-23, the invoice for the AC was submitted to inspector included AC unit replacement and other repairs to the facility?s AC system.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-90-40-B
Description:	Based on the employee record review, the facility failed to ensure no employee was permitted to work in a position that involves direct contact with a resident until a background check was received as required in the Regulation for Background Checks for Assisted Living Facilities and Adult Day Care Centers (22VAC40-90), unless such persons works under the direct supervision of another employee for whom a background check has been completed in accordance with the requirements of the background check regulation (22VAC40-90). Evidence: 1. On 6-30-23, staff #7 did not have a background check document in the record. The staff?s date of hire noted as 6-19-23.
Plan of Correction:	Not available online. Contact Inspector for more information.