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: Feb. 22, 2024

Complaint Related: No

Areas Reviewed:

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 on 2-22-24 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 #:	22VAC40-73-325-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 2-22-24, resident #3?s fall risk in the record was dated 12-13-22; resident?s date of admit noted as 2-22-18. The resident uses mechanical device to move around the facility. 2. Staff #2 and #3 acknowledged the resident?s record did not include a current/ annual fall risk rating.
Plan of Correction:	Review the fall assessment for Resident #3, ensure staff are trained properly, monitor quality closely, establish clear documentation guidelines, improve communication, foster continuous improvement, enforce accountability, and conduct follow-up reviews. Date of Correction: February 22, 2024
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that the resident?s individualized service plan (ISP) included all assessed needs for a resident. Evidence: 1. On 2-22-24, resident #3?s uniformed assessment instrument (UAI) dated 6-29-23 noted resident incontinent of bladder. The ISP dated 6-29-23 documented, resident?s bowel incontinence. Wheeling need assessed as not performed. The ISP noted resident does not need help; use of wheelchair, resident propels self independently in wheelchair. Stairclimbing accessed as mechanical help. The ISP noted stairclimbing not performed, the facility is a one level building. 2. Staff #2 and #3 acknowledged the resident?s ISP and assessed needs did not agree.
Plan of Correction:	Resident #3 is a public UAI, and their case worker conducted the UAI, noting that the resident is continent on both bladder and bowel; therefore, a note will be added to the ISP indicating occasional bowel incontinence to align with the ISP created by the case worker. Date of Correction: February 22, 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 2-22-24, the facility did not have signed and dated documentation of the annual review of resident?s rights and responsibilities for resident #1. The resident?s date of admit was dated 11-19-21. 2. Staff #2 and #3 acknowledged the resident?s record did not include documentation of resident?s rights and responsibilities.
Plan of Correction:	Review the R & R for Resident #1 Administration will establish clear documentation guidelines, improve communication, foster continuous improvement, enforce accountability, and conduct follow-up reviews. Date of Correction: February 22, 2024