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: Oct. 23, 2023 and Oct. 31, 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 A joint on-site monitoring inspection was conducted on 10-23-23, two inspectors from Peninsula licensing office. (AR 08:42 am./Dep 18:00. The facility census was 30. 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 #:	22VAC40-73-70-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it reported to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety or welfare of any resident. Evidence: 1. On 10-23-23, resident #2?s progress note dated 6-22-23 noted the resident was admitted to a local hospital for psychiatric treatment. The resident?s discharge summary document noted the resident admit days were 6-21-23 to 6-29-23. 2. Staff #1 acknowledged the resident?s psychiatric admission was not reported to the licensing office.
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: November 1, 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 10-23-23, staff #6?s record did not include a date the tuberculosis (TB) assessment was completed. The staff?s date of hire noted as 10-2-23. 2. Staff #9?s record did not include a date of the TB assessment was completed. The staff?s date of hire noted as 10-11-23. 3. Staff #1 and #2 acknowledged the staff?s record did not include the date the assessment was completed noting the absence of TB in a communicable form.
Plan of Correction:	A new Tuberculosis screening process is now a mandatory step in each hiring procedure. New employees must provide proof of their TB screening before they can commence work. Date to be started: November 1, 2023
Standard #:	22VAC40-73-260-C
Description:	Based on observation, staff interviewed, and document reviewed the facility failed to ensure the first aid/CPR listing indicating by staff person whether the certification is in first aide or CPR or both was kept up to date. Evidence: 1. On 10-23-23, the first aid and CPR posted in the medication room was not current. The names of staff members listed noted expired certificate date of 8/2023, 6/2023 and 1/2023. The last the document was updated was noted as January 17, 2022. 2. Staff #4 acknowledged the first aide/CPR listing posted was not current.
Plan of Correction:	Alerts will be sent via text and email to all staff members with CPR certifications expiring within 60 days of their renewal date. Additionally, monthly checks of postings will be conducted to prevent the recurrence of this issue. Date to be corrected: November 1, 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 10-23-23, resident #3?s record included a prescription dated 9-18-23 for Risperidone. The record did not include a psychotropic treatment plan for this medication. 2. Staff #4 acknowledged the resident?s record did not include a psychotropic treatment plan for Risperidone.
Plan of Correction:	Each new prescription will require a report copy to be sent to the Assistant Administrator, ensuring that the psychotropic treatment plan is updated. Additionally, staff members will document any new prescriptions in the new system when charting for the day. Date to be corrected: November 1, 2023
Standard #:	22VAC40-73-440-D
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the private pay uniform assessment instrument (UAI) was completed as require. Evidence: 1. On 10-23-23, resident #3?s UAI dated 10-3-23 was completed by facility staff #4, but not signed and dated by the administrator or designee. 2. Staff acknowledged, the resident?s UAI was not signed and dated by the administrator and/or designee.
Plan of Correction:	Each UAI must be communicated to the Assistant Administrator for her review and signature. RMAs who are responsible for completing the private UAI must submit the paperwork to the Assistant Administrator before filing it in the resident's chart. Date Corrected: November 1, 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 10-23-23, resident #3?s uniform assessment instrument (UAI) dated 10-3-23, bathing need was assessed as mechanical help/human help/physical assistance. The ISP dated 9-25-23 noted bathing as ?human and physical assistance---staff will supervise resident into the shower chair and stand by assist for safety?. Orientation noted resident disoriented some time to date and time; the ISP did not document what staff should do or how to assist the resident with this need. 2. Staff #2 acknowledged the UAI assessment and the ISP services were not the same.
Plan of Correction:	Each UAI must be communicated to the Assistant Administrator for review and signature. RMAs, responsible for completing the private UAI, must submit the paperwork to the Assistant Administrator before filing it in the resident's chart. This ensures that the ISP and UAI are appropriately aligned with each other. Date to be corrected: November 1, 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 10-23-23, staff #5?s date of hire date noted as 10-4-23, first day of work noted as 10-9-23. The staff?s background check document was dated 10-11-23. 2. Staff #7?s date of hire date noted as 8-25-23 and the staff?s background check document was dated 9-18-25. 3. Staff #8?s date of hire noted as 9-21-23 and the staff?s background check document was dated 10-3-23. 4. The facility did not have documentation of the staff members being provided with sight and supervision of a staff with a criminal background check during the time the background check was not completed.
Plan of Correction:	It conveys that if the background check results are delayed, the new hires will undergo shadowing and hands-on training with side-by-side supervision to avoid licensing violations.