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: Aug. 29, 2023 and Sept. 15, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint An on-site Complaint Inspection was conducted on 8-29-23. 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 8-22-23 regarding allegations in the resident care, staffing, supervision, and buildings and grounds. Number of residents present at the facility at the beginning of the inspection: 31 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: Number of staff records reviewed: Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 2 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 some, but not all of the allegations area(s) of non-compliance with standard(s) or law was valid A violation notice was 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 #:	22VAC40-73-280-A
Complaint related:	Yes
Description:	Based on observation and interviews, the facility failed to ensure 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, and to ensure compliance with this regulation. Evidence: 1. On 8-29-23, the facility census was thirty-one and there were two staff members available to provide medication and direct care needs. Resident #1 was observed agitated and requesting to use a phone. Record review, staff interview and resident interview determined the resident had a returned to the facility from a hospital stay. The resident would not provide the facility staff with a copy of the discharge documentation. Notes in the communication log documented there were medications changes but what specific medications were not documented. A review of the resident?s August 2023 medication administration record (MAR) documented resident prescribed Bupropion, Clonazepam, Adderall, and Venlafaxine. Resident #2 was agitated and wandering through the facility with a sweater smeared with fecal matter. A review of the resident?s chart documented resident cognitive impairment. 3. The direct care staff was diverted to the kitchen to prepare the breakfast meal because the cook walk-out. This is the second time the inspectors have come to the facility and direct care staff is in the kitchen preparing meals because there is no one to cook. On 6-30-23, the registered medication aide was administering medication and preparing the breakfast meal for 31 residents. 4. There was no activity staff available to provide activity during the inspector?s time at the facility. 5. The local transportation driver arrived to transport several residents to their day program but was delayed because the residents did not have breakfast, they were provided cold cereal. The residents were also waiting for their lunch to be prepared. Because there was no cook, the residents were prepared a bacon, lettuce and tomato sandwich and provided a rice Krispy treat and told to get a drink from the store at the day program.
Plan of Correction:	1. The Assistant to the Administrator will monitor the prescriptions of every resident returning to the facility from the hospital or any other clinic to ensure that the process is completed in a timely manner. Date to be Corrected: September 25, 2023 2. The Administrator will ensure that there is always enough staffing available to assist the residents. The Assistant to the Administrator will also re-train everyone to ensure that residents are properly dressed in clean clothing. Date to be Corrected: September 25, 2023 3. The Administrator will ensure there is backup staff available in case another staff member calls out. The Assistant to the Administrator will hire two dietary crew members for each shift to prevent any issues in case one of them calls out, ensuring that there is always a cook available. Date to be Corrected: September 25, 2023 4. Due to the staffing shortage, the activity was canceled. The administration will ensure that they post a notice of canceled activities when this issue arises in the future. Date to be Corrected: September 25, 2023 5. The Administrator will ensure there is backup staff available in case another staff member calls out. The Assistant to the Administrator will hire two dietary crew members for each shift to prevent any issues in case one of them calls out, ensuring that there is always a cook available. The facility will incorporate a lunch bag to be prepared the night before to ensure the availability of the packed lunch for everyone who goes to the day program. Date to be Corrected: September 25, 2023