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: Sept. 21, 2023 and Sept. 27, 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 conducted on 9-21-23 (Ar 07:40/dep 12:50 p.m). A medication pass observation conducted, breakfast and lunch meal observed, tour of the facility, resident and staff records reviewed. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The 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 #:	22VAC40-73-100-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 9-21-23 during the medication pass observation with staff #3, resident #3?s glucometer was not labeled with resident?s identifying information. 2. Staff #3 acknowledged the resident?s glucometer was not labeled.
Plan of Correction:	Colonial Manor has taken steps to address a citation by ensuring that all residents' personal equipment is properly labeled and cleaned according to infection control guidelines. This proactive approach is essential for maintaining a safe and hygienic environment for the residents and preventing future citations. Regular training and adherence to these guidelines will not only help in complying with regulations but also contribute to the overall well-being and health of the residents under their care. Date to be corrected: October 2, 2023
Standard #:	22VAC40-73-50-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the disclosure statement was provided to the resident and/or legal representative in advance of admission and prior to signing the admission contract. Evidence: 1. On 9-21-23, resident #1?s record did not include documentation of receipt of the disclosure statement. The resident?s date of admit noted as 6-8-23.
Plan of Correction:	1. It appears that there was a missing Disclosure Statement for a particular admission. To rectify the situation, the assistant to the Administrator took prompt action by completing the necessary form. Subsequently, the form was sent to the resident's guardian for their signature. This proactive approach ensures that all required documentation is in place and compliant with relevant regulations or procedures. Date to be corrected: September 21, 2023
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 9-21-23, resident #3?s progress note dated 8-21-23 document resident complained of chest and back pain. The resident was transported to the emergency room via 911 call. 2. Staff #2 stated sending an incident report, the licensing office have no report of an incident report for the aforementioned resident.
Plan of Correction:	It's commendable that Colonial Manor has taken steps to prevent incidents of failing to report important information to the licensing authorities. The facility can ensure that critical details are not overlooked by creating a new system that streamlines the process and makes it easier to input information. Additionally, the ability for management to promptly access and forward this information to the licensing authorities enhances transparency and compliance with regulations, ultimately benefiting both the facility and the residents it serves. This proactive approach to compliance is crucial for maintaining high standards of care and adherence to legal requirements. Date to be corrected: October 15, 2023
Standard #:	22VAC40-73-310-D
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the administrator provided written assurance to the resident that the facility has the appropriated license to meet the needs of the care needs of the resident at the time of admission. Evidence: 1. On 9-21-23, resident #1?s record did not have signed documentation of having received written assurance from the administrator of the facility having the appropriate license to the meet the resident?s care needs at the time of admission. Resident?s date of admit noted as 6-8-23.
Plan of Correction:	1. It appears that there was a missing Written Assurance for a particular admission. To rectify the situation, the assistant to the Administrator took prompt action by completing the necessary form. Subsequently, the form was sent to the resident's guardian for their signature. This proactive approach ensures that all required documentation is in place and compliant with relevant regulations or procedures. Date to be corrected: September 21, 2023
Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any prohibition condition per the Code of Virginia 63.2-1805 D. Evidence: 1. On 9-21-23, resident #3?s physician?s order dated 8-14-23 and September 2023 medication administration record (MAR) noted resident prescribed Paxil, start date of 3-13-23. The record did not include a psychotropic treatment plan.
Plan of Correction:	1. Providing education to Registered Medication Aides (RMA's) to ensure that all psychotropic medications have current treatment plans is a vital step in promoting the responsible and safe administration of such medications. Psychotropic medications can have significant effects on a resident's mental health, and having updated treatment plans is crucial for monitoring their usage and effectiveness while minimizing potential risks and side effects. Colonial Manor will demonstrate its commitment to resident safety and compliance with regulations. It also helps ensure that RMAs have the necessary knowledge and understanding to administer these medications responsibly and in alignment with the residents' treatment goals and needs. This proactive approach to medication management is essential in a healthcare setting. Date to be corrected: October 3, 2023
Standard #:	22VAC40-73-325-B
Description:	Based on record reviewed and staff interview, the facility failed to ensure the resident?s fall risk rating was reviewed at least annually, when resident condition changes and after a fall. Evidence: 1. On 9-21-23, resident #2?s record did not include an annual fall risk assessment, resident?s date of admit noted as 8-15-17. The fall risk document in the record was dated 7-21-22. 2. Resident #3?s fall risk was dated 7-3-21. The fall risk dated ?Dec 4/22? was signed by staff #1, but there was no assessment completed.
Plan of Correction:	Completing fall risk assessments and ensuring they are conducted annually for each resident is a crucial component of resident safety and regulatory compliance in healthcare settings. Falls can have serious consequences for residents, so proactive risk assessment and management are essential. Encouraging staff to routinely check each resident's chart for upcoming assessments is a practical approach to maintaining compliance with regulations and safeguarding residents' well-being. By implementing this process, Colonial Manor is demonstrating a commitment to proactive care and adherence to best practices in fall prevention. Regular assessments also allow for adjustments in care plans as needed, which can help mitigate fall risks and improve overall resident safety. This proactive and systematic approach to fall risk assessment and management is commendable and helps ensure a higher standard of care. Date to be Corrected: September 22, 2023
Standard #:	22VAC40-73-410-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the orientation for new residents and their legal representative included all the requirement information per the regulation. Evidence: 1. On 9-21-23, resident #1?s orientation documented 6-8-23 was not checked emergency response and mealtimes/menu provided. The document was not signed by the resident and/or legal representative, nor facility representative. 2. Staff #2 acknowledged the orientation form was not fully completed.
Plan of Correction:	1. Ensuring that all admission checklists are completed is a critical step in providing comprehensive care and adhering to regulatory requirements in healthcare settings. Colonial Manor has included these steps in the training provided to the admission team. This training helps ensure. 2. consistency and accuracy during the admission process, reducing the risk of oversights and ensuring that all necessary information and documentation are gathered. Date to be Corrected: September 22, 2023
Standard #:	22VAC40-73-440-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure an annual reassessment and reassessment due to significant change in the resident?s condition, using the uniform assessment instrument (UAI), was 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 9-21-23, resident #2?s record did not have documentation of a current uniform assessment instrument (UAI). The UAI in the record was dated 8-30-22. 2. Resident #3?s UAI was dated 7-21-21 and 3-21-22. 3. Resident #2 and #3?s UAIs are private pay assessments.
Plan of Correction:	1. 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 45 days. Date to be Corrected: November 15, 2023
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the comprehensive individualized service plan (ISP) included all assessed needs. Evidence: 1. On 9-21-23, resident #1?s individualized service plan (ISP) dated 7-8-23 did not include resident?s pacemaker, noted on the resident?s physical examination and social data form. The resident?s physical examination dated 5-18-23, immunization record and facility interview noted wheat, iodine, and gluten allergies, these needs were not noted on the resident?s social data form. The resident was observed walking a cane. Staff #3 and #4 stated resident uses cane sometimes. The uniformed assessment instrument (UAI) dated 6-8-23 documented walking need as no help needed. Stairclimbing need assessed as no help needed, the ISP documented resident requires supervision with stairclimbing. Resident?s orientation assessed as disoriented some time, the spheres were not documented.
Plan of Correction:	1. It's important to ensure that Individualized Service Plans (ISPs) accurately reflect a resident's specific needs and medical conditions. Corrected the ISP plan for Resident #1 to include information about the pacemaker. Date to be Corrected: October 5, 2023 Additionally, if Resident #1 is using a cane for safety reasons, even without a physician's recommendation, it's crucial to assess the situation. The Assistant to the Administrator's request for an evaluation to determine the appropriateness of using a cane as a security measure is a proactive approach. It demonstrates a commitment to resident safety and well-being, as well as a willingness to adapt the care plan to the resident's specific needs. Evaluations by healthcare professionals can help ensure that the resident's use of the cane is both safe and effective. Date to be Corrected: October 15, 2023 Updating the Uniform Assessment Instrument (UAI) for Resident #1's walking needs and reassessing their orientation to reflect in the Individualized Service Plan (ISP) is a crucial step in providing personalized and responsive care. This ensures that the ISP accurately reflects the resident's current condition and needs. Integrating the updated UAI information into the ISP aligns the care plan with the resident's specific requirements and helps in delivering the most appropriate and effective services. Regular assessments and adjustments like these are essential for maintaining high standards of care and ensuring resident well-being. Date to be Corrected: October 5, 2023
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (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 9-21-23, resident #2?s individualized service plan (ISP) was dated 8-20-22, the resident?s date of admit noted as 8-15-17. Documentation in the resident?s record, last ISP noted resident occasionally wanders. 2. Resident #3?s ISP was dated 7-2-22. The resident?s date of admit noted as 3-7-17.
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 45 days. Date to be Corrected: November 15, 2023
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 9-21-23, during the lunch meal observation, the residents were served turkey sandwich, some resident received sliced apples, some received red grapes, and a few were served tortilla chips. Those who received grapes were served four grapes in a 2-ounce cup, those who were served sliced apples received 4- to 5 slices of a small apple. There were twenty residents present and six residents received tortilla chips. The menu noted chips to be served with the turkey sandwich. All residents were not provided every item from the menu. The administrator and staff #2 were asked if the facility had chips available to serve the residents. Staff #1 and #2 replied chips were available. Staff #2 went to the food storage area in another section of the building and showed the inspectors an open box of ?tortilla chips?. 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. 3. The administrator was informed, every resident should receive all items unless the resident declines an item. The administrator, staff #1 stated they, referring to the residents did not need to be given everything, they would not eat it, and the food gets thrown in the trash. This reminder is often noted in the nutritional reports provided to the facility.
Plan of Correction:	1. Training the dietary crew to provide the right amount of food for each resident, in accordance with the guidelines from the US Department of Agriculture's Food guidance, is crucial for ensuring residents receive proper nutrition and adhere to dietary requirements. Additionally, the practice of offering all meals as specified on the menu, unless a resident has allergies or dietary restrictions, is important for delivering a high standard of care. By implementing these guidelines and providing training to the dietary crew, Colonial Manor is demonstrating a commitment to both regulatory compliance and the well-being of its residents. Proper nutrition plays a significant role in maintaining residents' health and quality of life, and adherence to dietary guidelines ensures that their dietary needs are met. Substitution options for residents with allergies or dietary restrictions further enhance the facility's ability to accommodate individual needs and preferences. Date to be Corrected: October 10,2023