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: Nov. 29, 2023 and Dec. 11, 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 22VAC40-90 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 11-29-23 (Ar 08:45 a.m./dep 12:10 p.m.) Facility census 30. The administrator was not present. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. An exit meeting will be conducted to review the inspection findings. 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, document 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 impacted affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. On 11-29-23, resident #1?s record included a discharge summary from a local hospital documenting an injury to the resident?s left forearm and parotiditis. 2. The resident?s progress notes dated 11-2-23 at 11:20 a.m. documented the resident?s family member inquired of facility staff, ?concern about a bruise on resident left forearm?the nurse practitioner contacted and stat order for an X-ray. 3. According to staff #1 and #3, facility did not know how injury occurred until being informed by the resident?s family member. 4. Staff #1 acknowledged; the facility did not know report the incident to the licensing office.
Plan of Correction:	1.Colonial Manor has implemented computer charting to ensure timely incident notifications to the administrator. This technological upgrade will facilitate prompt reporting and enhance our commitment to resident safety.
Standard #:	22VAC40-73-325-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a resident who met the criteria for assisted living care by the time the comprehensive individualized service plan (ISP) is completed, a written fall risk rating shall be completed. Evidence: 1. On 11-29-23, resident #1?s record noted a date of admission on 1-5-23, and the comprehensive service plan dated 2-5-23. The record did not include documentation of a written fall risk rating. 2. Staff #1 and #3 acknowledged the resident?s record did not include a fall risk rating.
Plan of Correction:	We recognize the critical importance of such assessments in ensuring the safety and well-being of our residents. Immediate corrective measures are being implemented to address this lapse: 1. Retrospective Assessment: A comprehensive fall risk assessment will be conducted for the resident in question without delay to rectify the initial oversight. 2. Review of Admission Procedures: We are reviewing and revising our admission protocols to ensure that fall risk assessments are consistently and promptly carried out for all new residents. 3. Staff Training: All relevant staff members will undergo retraining to emphasize the importance of conducting fall risk assessments upon admission and to reinforce adherence to established protocols. 4. Process Enhancement: We are enhancing our admission documentation process to include mandatory fields for fall risk assessment.
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s individualized service plan (ISP) included all assessed needs. Evidence: 1. On 11-29-23, resident #1?s uniformed assessment instrument (UAI) 2-7-23 noted bathing need as human help/physical assistance. The ISP dated 2-5-23 noted bathing as ?human help and supervision. Staff supervise resident into the shower chair and standby assistance for safety?. Toileting need assessed as human help/supervision. The ISP noted, ?mechanical & human supervision help. Resident use grab bars to maintain balance while transferring on/off the toilet?. Staff will supervise and assist per resident request and as needed?. Transferring assessed as no help needed. The ISP noted, ?mechanical & Human & Supervision assistance. Resident uses arms or chairs, and grab bars to transfer.? Walking assessed as mechanical help. The ISP noted, ?mechanical help and supervision. Resident will use a walker for balance to reduce the risk of injury while ambulating. Staff will supervise resident?safety and provide assistance as needed?. Stairclimbing assessed as human help/physical assistance. The ISP noted, ?mechanical, human help & supervision. Resident will use handrails when using stairs. Staff will supervise resident when using stairs for safety & provide assistance when needed?. 2. Resident?s personal and social data noted resident allergy to ?wheat, iodine and gluten?. The ISP noted, ?Allergies: NKA, no known allergy?. 3. Staff #1 acknowledged the aforementioned resident?s assessed needs and the services on the care plan did not agree.
Plan of Correction:	The error has been corrected promptly. Re-training and reminder discussions have been conducted with the staff responsible for the ISP and UAI to ensure accurate and consistent documentation in the future.
Standard #:	22VAC40-73-680-M
Description:	Based on record reviewed, observation and staff interviewed, the facility failed to ensure medications ordered for PRN, as needed, administration was available, properly labeled for the specific resident, and properly stored at the facility. Evidence: 1. On 11-29-23, following medication pass observation with staff #3, a check of the resident #2?s medication determined the following PRN medications were not available: (a) Albuterol U/D 0.083% solution for shortness of breath; (b) Eucerin cream for dry skin and (c) Almacone -2 liquid (Mylanta) for indigestion. 2. Staff # 3 acknowledged the resident?s PRN medications were not available on 11-29-23.
Plan of Correction:	1. The issue has been promptly addressed by resubmitting the order to the pharmacy for replenishment. We are committed to ensuring the continuous availability of medications as required.
Standard #:	22VAC40-73-700-2
Description:	Based on observation and staff interviewed, the facility failed to ensure it posted ?No Smoking-Oxygen in Use? sign and enforce the smoking prohibition in any room of the building where oxygen is in use. Evidence: 1. On 11-29-23, during a tour of the facility with staff #2 and #3, oxygen tanks and concentrator were observed in room 29. There was no sign posted indicating ?No Smoking-Oxygen in Use?. 2. Staff #2 and #3 acknowledged there was no sign posted for resident #2?s room where oxygen tanks and concentrator were present.
Plan of Correction:	Not available online. Contact Inspector for more information.