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: 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 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 conducted on 8-29-23 with two inspectors (LA/LI). AR (06:47 a.m./Dep 1:40 p.m). The facility census was 31. A final exit will be scheduled to review this inspection. 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 #:	22VAC40-73-100-C-2
Description:	Based on observation and staff interviewed, the facility failed to ensure implementation of the facility?s infection control prevention measures was conducted. Evidence: 1. On 8-29-23 during the medication pass observation with staff #3, resident #3?s glucometer was removed from its storage case and placed on top of a stack of papers located on the medication cart. The staff did not use gloves when administering the resident?s eye drops. The staff did not clean the resident?s nasal spray following intranasal use before returning it to its designated section of the medication cart. Staff administered resident #3?s eye drops without using gloves. 2. The large bottle of hand sanitizer on the medication cart was dated, 08/2021. The small bottle of hand sanitizer observed being used by staff #3 was dated 11/2018.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-70-A
Description:	Based on record reviewed, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or threatens the life, health or safety or welfare of any resident. Evidence: 1. On 8-29-23, resident #1 observed confused and agitated. Resident stated return from the hospital the previous night (8-28-23). The resident?s progress note did not document resident?s return. The resident?s progress notes in the record included a note dated 8-26-23 (11 a.m.) documenting the resident was sent to the hospital per resident?s request. A 4 p.m. documentation noted the resident was admitted to a local hospital-diagnosis of altered mental health. 2. The facility did not submit an incident report for resident #1?s admission to the hospital.
Plan of Correction:	1. The Assistant to the Administrator has introduced a new system for documenting incident reports. This system will streamline the process and enable timely submission of incident reports. Date to be Corrected: September 25, 2023 2. The Assistant to the Administrator has introduced a new system for documenting incident reports. This system will streamline the process and enable timely submission of incident reports. Date to be Corrected: September 25, 2023
Standard #:	22VAC40-73-250-D
Description:	Based on record reviewed, the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents shall submit the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. On 8-29-23, staff #6 `s record did not have documentation of the absence of TB in a communicable form. Staff?s date of hire noted as 8-16-23, first day of work noted as 8-18-23. 2. Staff #8?s record did not have documentation of the absence TB in a communicable form. Staff?s date of hire noted as 8-24-23.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that an annual reassessment and reassessment due to a significant change in the resident?s condition, using the UAI (uniform assessment instrument), shall be utilized to determine whether a resident?s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: 1. On 8-29-23, resident #1?s record did not have documentation of an annual reassessment using the UAI to determine resident?s needs and continued placement in the facility. Resident #1?s private pay UAI in the record was dated 5-20-20 and 5-20-21. The resident?s date of admit noted as 10-8-2008. 2. Resident #2?s record did not include documentation of a UAI. The resident?s date of admit noted as 11-26-14.
Plan of Correction:	The Assistant to the Administrator is conducting a review of all ISPs and working on reviewing & completing the Individualized Service Plans (ISPs) for residents who have annual requirements that need to be fulfilled. Assigning a few staff to attend an ISP class. The goal is to have all ISPs updated within 60 days. Date to be Corrected: November 15, 2023
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plans (ISP) was reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. On 8-29-23, resident #1?s record did not include an annual ISP. The document in the record noted it was reviewed by staff #1 and noted ?plan year May 2021? and ?revised Nov 7/22. The ISP also noted review date 5-20-22 and 11-7-22. Services to be re-evaluated 5-20-22. This same violation was cited on 2-10-23. 2. Resident #2?s record did not include an annual ISP. The resident?s date of admit noted as 11-26-14. 3. Resident #3?s ISP noted it was reviewed by staff #1 and noted ?revised on Dec-17-22?, expected outcome dates 1-17-22. 4. Staff #2 acknowledged the ISPs for the residents -#1 and #2 were not corrected and updated following the 2-10-23 violation.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-610-B
Description:	Based on observation, the facility failed to ensure menus for meals and snacks for the current week was dated and posted in an area conspicuous to residents. Evidence: 1. On 8-29-23, the menu for meals posted was dated 8-17 to 8-23-23.
Plan of Correction:	The menu was posted in a timely manner. Based on observations from staff and other residents, it has been noted that some residents prefer to have a physical copy of the menu. To accommodate this preference, the facility will ensure that every resident has their own copy by Wednesday of each week. Additionally, the facility will install a covered bulletin board to protect the posted menu copies from being taken by others. Date to be Corrected: September 25, 2023
Standard #:	22VAC40-73-650-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment was started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over the counter, and sample medications. Evidence: 1. On 8-29-23, resident #2?s record did not have documentation of a physician or other prescriber?s orders for medications administered by staff #3 during the medication pass observation. Aripiprazole (MAR noted original date 9-29-22, current written date 8-2-23). Progesterone (MAR noted start date 8-22-23). Citalopram (MAR noted original date 22-21-22, current written date 8-2-23). Bupropion (MAR start date 3-23-23). Buspirone- (MAR noted original date 8-2-19, current written 8-2-23). 2. Resident #3?s record did not have documentation of a physician or other prescriber?s orders for medications administered by staff #3 during the medication pass observation. Hydrochlorothiazide (MAR noted 7-31-23 start date). Diphenhydramine (MAR start date 4-17-23). Guaifen-PSE (MAR noted start date of 4-27-23, stop 8-21-23 and restarted 8-21-23). Saline Nasal Spray (MAR start date 4-27-23). GNP eye drop (MAR start date 8-21-23). 3. Staff #5 came to the facility to assist in locating the physician?s orders but was not able to locate them.
Plan of Correction:	Outside facility providers typically send prescriptions directly to the pharmacy. To maintain the accuracy of the Medication Administration Record (MAR) in relation to the posted prescriptions in each resident's chart, the facility will now require a copy of the prescriptions to be faxed by outside providers. Date to be Corrected: September 25, 2023
Standard #:	22VAC40-73-660-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the storage areas for the medications was locked. . Evidence: 1. On 8-29-23 during the medication pass observation with staff #3, staff walked away from the medication cart leaving it unlocked as staff went to assist staff #8 with accessing the housekeeping cart from a nearby room. Staff also left the cup of medications for resident #2 on top of the medication cart.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure medication was administered not earlier than one hour before and not later than one hour after the facility?s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: 1. On 8-29-23, resident #1?s August 2023 medication administration record (MAR) noted medications not administered according to the facility?s dosing schedule thirteen (13) days from August 2, 2023 to August 23, 2023. 2. Resident #2?s August 2023 MAR noted medications not administered according to the facility?s dosing schedule thirteen (13) days from August 4, 2023 to August 27, 2023. 3. Resident #3?s August 2023 MAR noted medications not administered according to facility?s dosing schedule fourteen (14) days from August 4, 2023, to August 27, 2023.
Plan of Correction:	Registered Medication Aides (RMAs) are undergoing training to ensure that they document in the resident's chart or leave a note if the resident chooses not to take their medication at the scheduled time. This is to prevent any missed medication notations on the Medication Administration Record (MAR). Date to be Corrected: September 25, 2023
Standard #:	22VAC40-73-710-B
Description:	Based on observation, record reviewed, and staff interviewed, the facility failed to ensure a medical restraint would only be used according to a physician?s written order and the written consent of the resident or the legal representative. Evidence: 1. On 8-29-23 during a tour of the facility with staff #1 and #2, resident #6?s bed was observed to have half-bed rails on both sides of the bed. The resident?s record did not include a signed physician?s order for use and no written consent of the resident or legal representative for this physical restraint.
Plan of Correction:	The facility will conduct a reassessment of the #6 resident's need for bed rail restraints and will obtain an order if necessary to ensure compliance with regulations. Date to be Corrected: October 2, 2023
Standard #:	22VAC40-73-860-I
Description:	Based on observation and staff interviewed, the facility failed to ensure that it stored cleaning and other hazardous materials in a locked area. Evidence: 1. On 8-29-23 during a tour of the facility with staff #1 and #2 hazardous materials were observed unlocked on the housekeeping cart located in the hallway near room #52. The facility provides services for residents with cognitive impairment. 2. Staff #1 acknowledged the hazardous items on the cleaning cart were not locked.
Plan of Correction:	The Administrator will arrange for the installation of a built-in door on the housekeeping cart. This measure is intended to ensure that residents with cognitive impairments are unable to access the cart. Date to be Corrected: October 15, 2023
Standard #:	22VAC40-73-870-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the interior and exterior of the building was maintained in good repair and kept clean and free of rubbish. Evidence: 1. On 8-29-23, during a tour of the facility with staff #1 and #2, the metal/aluminum awning covering was observed to be loose and falling from the roofing structure in a few areas in the rear of the building. Staff #1 reached up and tried to push the metal/aluminum material back in place. 2. The floors in the dining areas were very sticky when walking on its surface. 3. The recessed light located over the fireplace continued blink during the inspection. This was brought to the facility?s attention during the 6-30-23 inspection. This was shown to staff #2. 4. The laminate floor at the entrance to room #24 is severely scuffed/scarred and discolored.
Plan of Correction:	1 . The Administrator has scheduled the maintenance crew to come and repair the ceiling in the courtyard and attend to any other necessary structural repairs to ensure compliance with regulatory standards. Date to be Corrected: October 15, 2023 2. The facility has hired a new housekeeping staff member who will be responsible for maintaining cleanliness on all floors, including the dining room. This measure is aimed at ensuring that the floors are clean and safe for all residents to walk on without the risk of falling. Date to be Corrected: September 25, 2023 The facility will consult an electrician to assess the lighting in the lobby. This light has been changed multiple times and requires further attention to ensure that it functions properly. Date to be Corrected: October 15, 2023 4. The facility has hired a new housekeeping staff member who will be responsible for maintaining cleanliness on all floors. This measure is aimed at ensuring that the floors are clean and safe for all residents to walk on without the risk of falling. Date to be Corrected: September 25, 2023
Standard #:	22VAC40-73-970-A
Description:	Based document reviewed, the facility failed to ensure that the fire and emergency evacuation drill frequency and participation was in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). Evidence: 1. On 8-29-23, a check of the facility?s fire drills log did not include documentation of a fire and emergency evacuation drill for the month of July 2023.
Plan of Correction:	The administration will ensure that all training sessions are conducted on a monthly basis in compliance with the regulations for Assisted Living. Date to be Corrected: October 2, 2023
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 8-29-23, staff #8 did not have a background check document in the record. The staff?s date of hire noted as 8-24-23. Staff observed working without the supervision of another employee for whom a background check has been completed in accordance with the requirements of the background check regulations. 2. Staff #1 acknowledge the staff did not have a background check completed within 30 days and was not under the direct sight and sound supervision of another employee with a background check.
Plan of Correction:	1. The administration will ensure that background checks are conducted for all individuals before they can begin their job. Despite staffing shortages, this essential requirement had been temporarily overlooked to prioritize shift coverage and the onboarding of new hires. Date to be Corrected: September 25, 2023