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: Dec. 11, 2023 and Jan. 3, 2024

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 22VAC40-80 THE LICENSING PROCESS

Comments:

Type of inspection: Monitoring An unannounced Monitoring Inspection conducted on 12-11-23 by two inspectors from the Peninsula Licensing Office (Ar 09:10 a.m./dep 16:10 p.m. Census was 29, administrator and assistant not present, but arrived later during the inspection. 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 (Wilie.Barnes), Licensing Inspector at (757- 439-6815) or by email at Willie. Barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-80
Description:	Based on record reviewed and staffs interviewed, the facility failed to ensure that there was documentation that the resident had requested the facility to assist with the management of personal funds. Evidence: 1. On 12-11-23, the facility did not have documentation of the resident?s request that the facility assists with the management of personal funds for resident #1, #2, #3 and #4. 2. Staff #1 and #2 stated the residents have debit cards that document the resident?s personal funds and tracks the resident's spending. Staff stated keeping debit cards for residents #1, #3 and #4 in the office. 3. When asked to review the documentation signed and dated by the resident giving the facility permission to assist with maintain the debit card, staff #1 and #2 stated not having documentation of this request and delegation. 4. On 12-11-23, staff #1 and #2 acknowledged not having documentation in the residents? record of the residents? request and delegation for the facility to assist with management of personal funds.
Plan of Correction:	The Colonial Manor administration office has developed a form that residents sign as part of the delegation statement process, and these signed forms will be kept in each resident's record to ensure compliance with state regulations. Date to be corrected: January 5, 2024
Standard #:	22VAC40-73-120-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the staff record included documentation of the staff oriented to the facility?s organizational structure within seven working days of employment. Evidence: 1. On 12-11-23, staff #5?s record did not have documentation of the organizational structure. The signature and date section of the document in the record was blank. 2. Staff #2 acknowledged the organizational chart was not signed and dated by the staff, acknowledging the training occurred within the first seven working days of employment.
Plan of Correction:	The administration office provided a new employee with a printed copy of the organizational chart to sign, and the signed copy has been posted in the employee's record. Additionally, a check-off form has been created for each employee record to ensure the completion of all necessary forms and prevent any oversights. Date to be corrected: January 5, 2024
Standard #:	22VAC40-73-210-E
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure staff completed training relevant to the population in care and shall be provided by qualified individual through in-service training programs or institutes, workshops, classes, or conferences. Evidence: 1. On 12-11-23, a review of staff #1?s record did not include documentation of staff training for the population in care. The record did not include documentation of oxygen training and training for adults with mental impairments. The facility currently has residents with diagnosis of schizophrenia, bipolar and other mental impairments other than dementia. 2. Staff #1 acknowledged not having all required training.
Plan of Correction:	The administrator has enrolled in a class for additional required training, and upon completion, the certification will be promptly posted in his file. Furthermore, all training certifications are consistently displayed in the breakroom for everyone's visibility. Date to be corrected: February 15, 2024
Standard #:	22VAC40-73-450-F
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the resident?s individualized service plan (ISP) reflected the assessed needs. Evidence: 1. On 12-11-23 resident #8?s private pay uniform assessment instrument (UAI) dated 5-20-23 noted feeding/eating assessed as no help needed. The individualized service plan (ISP) dated 5-20-23 noted the resident?s meal is mechanical soft. The resident?s physician?s order dated 10-20-22 also noted a mechanical soft diet with thicken nectar liquids. 2. Resident #1?s public pay uniform assessment instrument (UAI) dated 10-31-23 noted feeding/eating assessed as no help needed. The resident?s physician?s order dated 11-16-22 noted a mechanical soft diet. The ISP dated 11-1-23 noted a mechanical soft diet. The UAI also noted resident?s allergy to Sulfa drugs, this was not noted on the ISP. 3. Staff #2 and #4 acknowledged the resident?s meal/feeding on the UAI was not accurately assessed; resident?s diet is mechanically altered- mechanical help. 4. Staff #2 and #4 acknowledged the residents? UAI and ISP did not agree.
Plan of Correction:	The private UAI will undergo a thorough review and be mirrored on the Individualized Service Plan (ISP). In the case of the public UAI, communication will be established with case workers, advising them to schedule regular meetings for review to ensure the accuracy of the UAI in reflecting everyone's daily routine and capabilities. Date to be corrected: January 5, 2024
Standard #:	22VAC40-73-610-C
Description:	Based on observation, document reviewed, staff and resident interviews, the facility failed to ensure the items noted on the posted menu were served and or substitutions noted and meet the U.S. Department of Agriculture?s food guidance system or dietary allowances of the Food and Nutritional Board of the National Academy of Sciences, taking into consideration of the age, sex, and activity of the residents. Evidence: 1. On 12-11-23, the lunch menu posted noted ham and cheese sandwich, French fries, chips, and fresh fruit. Interviews and observation of resident?s plate noted, grilled cheese sandwich on hot dog buns for some residents, three to four strips (approximately 1 inch) of ham were on the side of the plate. Also observed were three to four grapes and a thinly sliced orange on the plate. There were not chips observed on the residents? plates. None of the residents interviewed stated receiving chips. 2. On 12-11-23, the two bags of 7/8 ounce chips in the food storage area were dated 12-5-23. The inspectors did not observe any other chips in the food storage areas (the kitchen, food storage across from administrator?s office and room 22). There was no substitution for the chips noted on the posted menu. 3. Dietary staff interviewed, stated, the food for the menu for the day is provided by the administrative staff and whatever is provided is what is served.
Plan of Correction:	The facility has employed a new Coordinator exclusively dedicated to monitoring the kitchen. This Coordinator will be responsible for submitting all necessary items for ordering, and menus will be crafted based on ingredients and supply availability in the pantry. A new contract with Sysco has been initiated to ensure consistent delivery of supplies. Date to be corrected: December 15, 2023
Standard #:	22VAC40-73-680-M
Description:	Based on observation, document reviewed, and staff interviewed, the facility failed to ensure medications ordered for PRN administration was available, properly labeled for the specific resident and properly stored at the facility. Evidence: 1. On 12-11-23 during a medication observation pass with staff #4, resident #8?s Tussin (Robitussin) noted on the physician?s order dated 12-3-23 and December 2023 medication administration record (MAR) was not available on the medication cart and not in the facility. 2. Staff #4 acknowledged the resident?s PRN Tussin (Robitussin) was not available on the medication cart and not in the facility.
Plan of Correction:	A new memorandum has been established instructing the facility to fax any medication orders following each visit from the Primary Care provider. The pharmacy will then assess and determine the new and current orders for the residents, aiming to prevent any missing information after each visit. Date to be corrected: January 9, 2024
Standard #:	22VAC40-73-870-E
Description:	Based on observation and staff interviewed, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition. Evidence: 1. On 12-11-23 during a tour of the facility with staff #4, the secure sealant to the pipe/tubing for the hot water heater locater in the laundry room near the nursing station was coming apart from the ceiling. The metal/stainless steel was not sealed/flushed and grounded to the ceiling. This issue was previously cited on 5-4-23. 2. Staff #4 acknowledged the fixture was not in good repair and condition.
Plan of Correction:	The facility has initiated another order to address the pipe issue on the ceiling. Additionally, the dryer, which was causing the pipe to shift due to squeezing, has been relocated away from the problematic area. Staff members have also been educated to avoid overloading machines to prevent excessive shaking, which could compromise the stability of the pipe. Date to be corrected: December 15, 2023
Standard #:	22VAC40-73-980-H
Description:	Based on observation, staff and collateral interviews, the facility failed to ensure the food supply was current. Evidence: 1. On 12-11-23 during a tour, the facility?s current rotating food stock, the following items were noted with expired dates: (a) Raspberry Walnut Vinaigrette dressing- 1 gallon container, dated 8-14-23, (b) Peanut Butter, dated 11-25-23, (c) Grated Parmesan Cheese, 2- 24 oz, dated 12-26-22 and 11-6-23; (d) Grits, 3- 80 ounce packages, dated 8-7-23 and (d) Garlic Parmesan Wing Sauce- 64-ounces, dated 9-19-23. Potato chips were noted earlier with menu. 2. There were also dented items on the shelf: Spaghetti Sauce, 2 (6.63 pound- #10 cans), Mandarin Orange- 1 can and a can of Cream of Mushroom soup. 3. Staff #1, #2, and #4 acknowledged the facility?s food supply contained dented cans items and foods with expired dates.
Plan of Correction:	The administration office has communicated with Sysco, notifying them that Colonial Manor will reject the delivery of any shipment with damaged or dented items. Additionally, a newly appointed Coordinator, solely dedicated to kitchen monitoring, will be responsible for identifying and removing any expired or dented items from the supply inventory. Date to be corrected: December 15, 2023