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 31, 2023 and Aug. 16, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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 07-31-23 (AR 12:48 p/m./ Dep 5:00 p.m. The facility census was 31. The administrator was not present but arrive later during the inspection process. A tour of the facility was conducted, lunch meal observed, staff 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) 439-6815or by email at willie.barnes@dss.virginia.gov

Violations:

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 7-31-23, staff #6, was documented on the staff schedule as the direct care staff for the 6 a.m. to 2:30 p.m. shift. Staff #6?s record was reviewed for documentation of staff?s credentials for direct care training. The staff?s record did not have documentation of training for a direct care. This violation for this staff was also cited on 6-30-23. The staff was observe working alone as a direct care staff, there was no staff shadowing this staff. Staff stated just doing what staff knew to do for the resident who needed assistance with activities of daily living. Staff acknowledged not having any formal training or taking a class with an instructor. 2. The facility has residents whose needs including hoyer transfer lift, oxygen use, assistance with feeding and incontinent care. Staff #6?s record did not include training in these service needs areas. 3.This violation was cited 6-30-23 for the same staff.
Plan of Correction:	Staff #6 was identified as deficient for direct care training and had received the required training effective July 14, 2023, and the training certificate was signed off on by contracted individual. The training certificate had been placed in the file but may not have been reviewed by the reviewer at the time of the site visit. The certificate of training is attached. Staff #6 did receive orientation training on the care needs of facility residents including the use of the Hoyer transfer lift, oxygen use, and assistance with feeding and incontinent care. While some of these trainings were addressed in the training conducted by contracted individual, additional training such as oxygen use was conducted by qualified staff member of the facility. To prevent future violations of this regulation, the facility is developing a check sheet to document review of care plan/needs of each resident for each staff hired to worked with the resident. The care needs of each resident will be specifically addressed on the check sheet and signed and dated by each employee responsible for care of the resident. The check off sheet will be maintained in the training record of the employee with a code designated for the specific resident discussed. The resident code sheet will be maintained by the assistant to the administrator Each staff will receive a check off on each resident and documentation filed by October 31, 2023.
Standard #:	22VAC40-73-520-I
Description:	Based on observation, the facility failed to ensure the scheduled activity was provided. Evidence: 1. On 7-31-23, the activity schedule noted coffee and cookies at 2:00 p.m. There was no activity provided between 2:06 p.m. and 4:00 p.m. 2. This violation is a repeat from 6-30-23 monitoring.
Plan of Correction:	The Activities Coordinator has addressed the issue of following the scheduled and posted activities schedule with all staff. The Activities Schedule is regularly posted on the Bulletin Board along with the menu and other required activities. To prevent future violations of these regulations, staff will be required to document a review of the Bulletin Board postings at the beginning of each shift and sign off on an acknowledgment sheet prior to beginning their shift. Staff responsible for the implementation of the activities will document the completion of the activity daily. The Activities Coordinator will coordinate with staff weekly on the scheduled activities and monitor the sign-off sheets as well as the documentation of the activities. Each activity scheduled will be documented as completed or provide explanation why the activity is not accomplished. Any change of scheduled activity must be approved by the activity coordinator or the assistant to the administrator. All staff will be oriented on these requirements and the consequences of failing to implement these procedures. Orientation to be completed by September 1, 2023.
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 7-31-23, 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 #2 stated that facility did not have a movable thermometer. 2. This is a repeat violation from the monitoring inspection conducted on 6-30-23 when the facility experienced AC (cooling) problems and was asked if a moveable thermometer was available in the facility to measure the temperatures in the facility.
Plan of Correction:	Individual rooms in the facility each have a working thermometer on the wall that reflects the temperature in the rooms. Due to the building being heated and cooled via units in zoned areas, the temperature does fluctuate as well as during periods when a zoned unit may not be functioning properly. To prevent future violations of this regulation the facility has purchased two (3) moveable thermometers with one also being capable of measuring the humidity inside the building. Staff will be trained on the use and storage location of these devices for use when necessary. Training of all staff will be completed by September 1, 2023.
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 7-31-23, during a tour of the facility with the administrator (staff #1), staff #2 #3 and CS-1, the Air Conditioning (AC) system was not operational throughout the facility. On the Residential Hallway, the AC was not operational in several residents? rooms, room #13, 17 and 27 were checked during the tour with facility administrator and consultant. 2. The AC in the small dining room across from the main dining room, was not providing cool air to the residents as they were gathered to watch TV. 3. The AC not operational throughout the building is a repeat violation from 6-30-23. The invoice provided on 7-13-23 noted cooling to public area, manager?s office and room 13. 4. The administrator acknowledged the AC unit was not operational in all areas of the building. This is a repeat violation from 6-30-23.
Plan of Correction:	The Administrator and agency HVAC vendor completed an evaluation of the room air conditioners in the facility and is in the process of developing a capital improvement plan to address HVAC concerns. The facility put in a new AC unit in Room #13. An AC Compressor was purchased for the AC unit in both rooms 17 and 27. AC components had been purchased and were awaiting arrival and installment to address the malfunctioning units in the dining areas. A follow-up review with the HVAC Vendor is scheduled for Thursday evening 8/24/2023 to assess corrective measures taken with the facility?s HVAC system. Individual room Acs currently functional.
Standard #:	22VAC40-73-890-B
Description:	the facility failed to ensure all interior was adequately lighted for safety and comfort of residents and staff. Evidence: 1. On 7-31-23, during a tour of the facility, the lights near rooms 5-6 and 17 and 18 were not lite. 2. Staff #1 (administrator) and CS-1 acknowledged the lights needed a bulb
Plan of Correction:	Bulbs were placed in the lighting fixtures for rooms 5-6, 17 and 18. The lights are currently functional. To prevent future violations of this regulation, the facility has hired an additional maintenance staff to monitor and perform required maintenance activities such as installing lighting, monitoring HVAC performance issues, and cleaning concerns. The staff is in the process of completing orientation but is already implementing improvements in cleaning and maintenance.
Standard #:	22VAC40-73-890-C
Description:	Based on observation and staff interviewed, the facility failed to ensure the glare was kept to a minimum in rooms used by residents by providing covering on the lights. Evidence: 1. On 7-31-23, during a tour of the facility with staff #1 (administrator, staff #2 and CS-1, the lights on the Residential Hallway was observed to not have a covering to reduce glare. 2. Staff #1 acknowledged the lighting did not have coverings.
Plan of Correction:	Lights in the Residential Hallway were recently installed but the covering for those units was falling and presenting a potential hazard to residents, employees, and visitors. Upon falling they would break or chip and replacements are not available. Therefore, the decision was made for safety reasons not to try replacing the defective coverings. This lighting is being included in the agency?s capital improvement plan to replace those recently purchased units with new lights. A plan to replace being reviewed with maintenance who will review alternatives to include cost and present to administrator within 45 days.
Standard #:	22VAC40-80-120-E-2
Description:	Based on observation and staff interviewed, the facility failed to ensure that the findings of the most recent inspections are posted in the facility. Evidence: 1. On 7-31-23, during the monitoring inspection, the inspections for 6-30-23, complaint and monitoring inspections were not posted. 2. On 6-30-23, during the monitoring and complaint inspection, the administrator was reminded of the requirements for the posting of all required inspections, not just the current Notice of Intent (NOI).
Plan of Correction:	The Assistant to the Administrator had posted the latest inspection in a binder, but the report was moved. To prevent future violations of this regulation, the Licensing Inspections will be posted in the foyer of the building near the sign-in roster with a visible post or announcement in the area pointing to the location of the Inspection Report. The Reports will be in a Binder on the Cabinet where the sign-in logs are located such that they are accessible to anyone wishing to review them.