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: Jan. 22, 2024 and Feb. 28, 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

Comments:

Type of inspection: Monitoring An unannounced monitoring inspection was conducted. The focus of the inspection was to determine whether the provider had corrected or is in the process of correcting previously cited violations in the areas of standards referenced above. Any non-compliant elements of law or regulations are documented in the Violation Notice of this inspection. This inspection found the provider to demonstrate noncompliance with standards not identified in the plan of correction. An unannounced monitoring inspection was conducted on 1-22-24 with two inspectors from the Peninsula Licensing Office. The facility census was 31. 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 #:	22VAC40-73-250-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that a staff personal and social data included all required information. Evidence: 1. On 1-22-24, staff #4?s record did not include verification of having received a copy of the staff?s current job description. Staff?s date of hire noted as 12-19-23 as a personal care aide/direct care staff. 2. Staff #2 acknowledged the staff?s record did not include a signed job description.
Plan of Correction:	After the inspection, the job description was promptly filed in the staff #4 folder and duly signed by staff #4. The Assistant Administrator has developed a checklist outlining the essential documents required in each file, ensuring their inclusion in subsequent hiring processes. Date to be corrected: January 25, 2024
Standard #:	22VAC40-73-260-C
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the posted listing of staff person with certification in first aid or cardiopulmonary resuscitation (CPR) was kept up to date. Evidence: 1. On 1-22-24, the first aid/ CPR posting in the nursing station reviewed with staff #3 did not include staff #4, date of hire 12-19-23. 2. Staff #3 acknowledged that staff?s name was not included on the posted first aid/CPR listing.
Plan of Correction:	Staff number 4's CPR record was promptly integrated into the current CPR lists displayed at the nurse station. The administration will annotate the date of the file update to ensure that all new hires are included in the latest posted list. Date to be corrected: January 22, 2024
Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit nor retain individuals with prohibited conditions or care needs. Evidence: 1. On 1-22-24, resident #4?s record documented resident prescribed Lorazepam psychotropic medications, (admission physical and POS). The record did not include a psychotropic treatment plan. 2. Staff acknowledged the aforementioned resident?s record did not include a psychotropic treatment plan for the Lorazepam.
Plan of Correction:	All psychotropic medications will be accompanied by a treatment plan. A meeting was held with all Registered Medication Aides (RMAs) to ensure that physicians sign off on these treatment plans as mandated by state regulations. Additionally, it's noted that Resident #4's treatment plan has been submitted to the Hospice Company to obtain the signature from the Hospice doctor. The Assisted Living Facility is committed to complying with all relevant regulations. Date to be corrected: January 22, 2024, February 5, 2024
Standard #:	22VAC40-73-325-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the fall risk rating was reviewed and updated at least annually for a resident. Evidence: 1. On 01-22-24, resident #1?s fall risk in the record was dated 12-2-22; resident?s date of admit noted as 12-1-19. The resident is assessed as physically non-ambulatory and uses a geri-chair for mobility. 2. Resident #3?s fall risk in the record was dated 5-1-21 and revision dated noted 12-2-22; resident?s date of admit noted as 7-24-19. The resident is assessed as physically non-ambulatory and uses a high-back wheelchair for mobility. 3. Staff #1 and #3 acknowledged the aforementioned residents? record did not include a current/ annual fall risk rating.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a plan of care was developed to address the basic needs of the resident on or with in seven days prior to the day of admission. Evidence: 1. On 1-22-24, resident #4?s care plan in the record need date was noted as 1-12-24. The date of the care plan developed by staff #3 and #4 was as 1-11-24. The resident?s date of admit was noted as 1-10-24. Staff #2 verified resident #4?s date of admit as 1-10-24. 2. Staff acknowledged the aforementioned resident?s care plan was not developed on or prior to admission.
Plan of Correction:	All psychotropic medications will be accompanied by a treatment plan. A meeting was held with all Registered Medication Aides (RMAs) to ensure that physicians sign off on these treatment plans as mandated by state regulations. Additionally, it's noted that Resident #4's treatment plan has been submitted to the Hospice Company to obtain the signature from the Hospice doctor. The Assisted Living Facility is committed to complying with all relevant regulations. Date to be corrected: January 22, 2024, February 5, 2024
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s updated individualized service plan (ISP) included all assessed needs. Evidence: 1. On 1-22-24, resident #1?s physician?s orders dated 09-27-23 and 6-8-23 noted resident prescribed a puree diet. The ISP dated 10-2-23 documented resident receives a mechanical soft diet. The resident was observed being spoon-fed a mechanical soft diet by staff #5 during the breakfast and lunch meals. The approximate time needed for meals to ensure needs was met was not documented on the resident?s ISP. The resident was observed eating and being pushed by staff in a geri-chair, this item was not documented on the resident?s ISP. The resident assessed as disoriented some spheres all the time. The ISP noted resident to be redirected but did not state how or when staff should redirect. The resident was also assessed as verbally aggressive, but staff stated resident did not talk. 2. Resident #2?s UAI dated 6-1-23 noted bathing need assessed as mechanical help/physical assistance/human help. The ISP dated 6-12-23 noted ?staff will supervise resident into the shower chair and standby assistance for safety?. Dressing need assessed as mechanical help/physical assistance/human help. The ISP noted, ?human help with physical assistance; resident will receive help from Direct Care Aide?. The care plan did not document what mechanical device was needed to provide care. Walking need assessed as yes but no category is assessed. The ISP noted ?walking with mechanical help with supervision?. Resident observed walking to around the facility, up and down the hallway without staff supervision. The fall risk information on ISP noted ?resident cannot walk independently without any assistance.? Resident observed using a sippy cup during breakfast and lunch meal. The record did not have documentation or a physician?s order for a special cup for drinking. Staff #1 stated staff provides cup to keep resident from spilling liquid on clothing. The resident?s physician?s order dated 10-11-23 noted ?no concentrated sweets (NCS) diet?, the ISP noted regular diet. 3. Staff #2 acknowledged the aforementioned residents? UAI, record documents and ISP did not include all assessed needs.
Plan of Correction:	1. All new physician orders, including diet orders, must be carefully reviewed. In response to this requirement, the office has requested physicians to sign a new set of diet order forms to ensure thorough documentation and compliance with regulations. This measure aims to enhance the accuracy and completeness of resident care plans. 2. The Individual Support Plan (ISP) and Uniform Assessment Instrument (UAI) must align, but concerns have arisen regarding discrepancies between the Private and Public UAI. Due to the unavailability of the case worker to correct or update the UAI, the ISP will include annotations explaining any changes. This ensures that reviewers or inspectors understand the reasons for any discrepancies between UAI and ISP for Public UAI residents. Date to be corrected: January 23, 2024
Standard #:	22VAC40-73-550-G
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure that the residents? rights and responsibilities were completed annually. Evidence: 1. On 1-22-24, the facility did not have signed and dated documentation of resident #1, #2 and #3?s annual resident rights and responsibilities. Staff #3 stated the resident rights were conducted 10-6-23. 2. During the exit meeting on 1-22-24, staff #2, dated resident #3?s annual rights as ?10-6-23 and Jan 22/2024 AOH?. 3. Staff acknowledged the resident?s rights were not signed and dated.
Plan of Correction:	Colonial Manor conducts an annual Rights & Responsibility Acknowledgement with all residents. To maintain thorough documentation, Colonial Manor will ensure that each signed document is dated and filed in the chart of each resident. This process guarantees compliance with regulatory requirements and facilitates efficient record-keeping for resident care. Date to be corrected: January 22, 2024
Standard #:	22VAC40-73-610-B
Description:	Based on observations and staff interviewed, the facility failed to ensure menu substitutions or additions was recorded on the posted menu. Evidence: 1. On 1-22-24, the posted breakfast menu for the day noted waffle with cheese sandwich, scrambled eggs, grits, cold cereal, and fruit (sliced apple). Pancakes with syrup was observed served during the breakfast meal. The menu did not note a change or substitution for the pancakes observed. 2. Staff acknowledged the menu was not updated to note the change or substituted item.
Plan of Correction:	Any changes to the posted menu will be promptly corrected. A meeting was held with the Dietary crew to underscore the importance of this rule. Additionally, it was emphasized to each member of the dietary staff that any changes must be reported to management for authorization, as all posted menus are verified to ensure availability. This ensures consistency and accuracy in meal offerings for our residents. January 22, 2024, February 5, 2024
Standard #:	22VAC40-73-640-A
Description:	Based on record reviewed, observation and staff interviewed, the facility failed to ensure it followed its medication management policy. Evidence: 1. On 1-22-24, following the medication pass observation with staff #3 and a check of PRN (as needed) medication, resident #3?s Nitroglycerin for chest pain had an expiration date of 3-24-23. 2. Staff # 3 acknowledged the resident?s PRN medication was outdated and not available.
Plan of Correction:	Colonial Manor will liaise with the Pharmacy to confirm whether the previously conducted cart audit included the removal of expired medication. The administration will compile a list of all medications pulled during each cart audit. Furthermore, a meeting with Registered Medication Aides (RMAs) was held to reinforce the importance of conducting thorough weekly inspections for expired medications, which will then be promptly removed and sent to the Pharmacy for proper disposal. Efforts will also be made to procure replacements for any expired medication. This proactive approach ensures the safety and well-being of our residents by maintaining the integrity of their medication supply. Date to be corrected: January 22, 2024, February 5, 2024
Standard #:	22VAC40-73-870-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the interior of the building was maintained in good repair. Evidence: 1. On 1-22-24 during a tour of the facility, the ceiling in the new dining room on the assisted living level hallway was observed to have a stain area in the ceiling that was approximately 12 by 8 inches. 2. Staff #2 acknowledged the ceiling was stained.
Plan of Correction:	A new dining room ceiling was stained, and a maintenance order was promptly dispatched to rectify the issue. The ceiling was repainted with the closest color available to restore its appearance. This swift action ensures the upkeep and aesthetic appeal of the dining area for the comfort and satisfaction of our residents. Date to be corrected: January 25, 2024
Standard #:	22VAC40-73-980-H
Description:	Based on observations and staff interviewed, the facility failed to ensure the availability of the 96-hours supply of emergency food which include the facility?s rotating stock used was kept current. Evidence: 1. On 1-22-24 the facility?s current rotating food stock, the following items were noted with expired dates: (a) Tortilla chips, 5 boxes of 36 (1.5 oz bags) noted an expiration date 13-Oct 2023, (b) Mac and Cheese, 9 boxes ( 7.25 oz) noted a best by date 10-Dec 2022; (c) Mayonnaise, 2 (1 gal) jars, noted a best by date 01-08-2024; (d) French Style green beans, 1 can (12.oz), expired 12-28-2023 and (e) Parboiled yellow rice, 1 bag (10 oz)2, best by Sep 20, 2023; (f) 2. Staff #1 and #2 acknowledged the facility?s food supply contained foods with expired dates/best by dates.
Plan of Correction:	All expired food items have been promptly removed from the pantry. A meeting was conducted with the kitchen crew on February 5 to emphasize the importance of verifying expiration dates on all supplies and ensuring proper rotation with every new delivery. This proactive approach guarantees the freshness and quality of our food supplies, upholding our commitment to providing safe and nutritious meals for our residents. Date to be corrected: January 22, 2024, February 5, 2024