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: March 21, 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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

Comments:

Type of inspection: Monitoring An unannounced on-site monitoring inspection was conducted on 3-21-24. (AR: 8:00 a.m. Dep: 12:20 p.m.), The facility census was 29. 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 #:	22VAC40-73-310-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 3-21-24, resident #1?s was administered Bupropion (Wellbutrin) during the medication pass observation with staff # 2. The resident?s March 2023 medication administration record noted the resident prescribed Bupropion daily for mood. The medication label also noted the resident?s Bupropion HCL XL 300 mg tablet. The record did not have documentation of a psychotropic treatment plan for Bupropion. 2. Staff #1 and #2 acknowledged the resident?s record did not include a psychotropic treatment plan for the Bupropion prescribed.
Plan of Correction:	The action plan entails initiating persistent communication with the outside doctor to obtain their signature for Wellbutrin on the treatment plan. A clear documentation protocol will be established, and staff, particularly Registered Medication Aides, will be trained to attach necessary forms when sending medication orders. Regular reviews of treatment plans will ensure accuracy, while continuous monitoring and feedback will guide adjustments. Thorough documentation will be maintained to track progress and address any recurring issues, ensuring comprehensive care for residents at Colonial Manor. Date Corrected: March 26, 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 3-21-24, resident #3?s fall risk in the record was dated 2-1-22. The facility?s ?Fall Risk Scale Assessment? document noted a score of 35, with instructions to initiate a care plan. The assessment form also documented it was revised by staff #7 on 10-20-22, however, the document did not include fall scores and or areas reviewed. 2. Staff #1 and #2 acknowledged the resident?s record did not include a current/ annual fall risk rating.
Plan of Correction:	The action plan involves educating staff on the importance of conducting fall assessments annually and with each new resident's fall incident. This includes ensuring the new form is included in each assessment and that points are totaled accurately. Additionally, there will be a monthly review of the fall assessment for each resident to monitor any changes or trends. This comprehensive approach aims to enhance resident safety and minimize fall risks at all times. Date Corrected: March 21, 2024
Standard #:	22VAC40-73-440-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure an annual reassessment, using the uniform assessment instrument (UAI), was utilized to determine whether a resident?s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: 1. On 3-21-24, resident 1?s record did not have documentation of a reassessment using the public pay UAI. The public pay UAI in the record was dated 3-2-22. The documented noted it was revised by staff #7 on 11-9-22. Staff #7 not qualified to complete public pay UAI. 2. Staff #1 acknowledged the resident?s record did not have documentation of a reassessment using the UAI since 3-2-22.
Plan of Correction:	Following multiple unsuccessful attempts to obtain the UAI for Colonial Manor through email and phone calls to the support coordinator, an immediate resolution was achieved by directly contacting the office and requesting to speak with the supervisor, resulting in the prompt delivery of the UAI to my attention and its posting in the Resident chart. Communication to the Support Coordinator will continue to achieve a prompt response before it expires. Date Corrected: March 25, 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 3-21-24, resident #3?s physician?s order sheet (POS) dated 1-2-24, noted resident?s allergy to Prozac. The resident?s ISP dated 5-8-23 noted the resident had ?no known allergy?. 2. Staff #1 and #2 acknowledged the resident?s ISP did not include resident?s assessed need.
Plan of Correction:	The Corrective Action Plan (CAP) for the missed inclusion of allergy information in Resident #3's Individualized Service Plan (ISP) entails implementing diligent monitoring by the administration office throughout the ISP writing and review process to prevent the recurrence of such oversights. This correction was immediately done after the licensing inspector left. Date Corrected: March 21, 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 3-21-24, the LI observed the breakfast meal being served. The fruit served was clementine. The residents? plates were observed to contain half of a small clementine. Staff #5 was asked to show the inspector the fruit being served with breakfast. A bag of small clementines was observed being used for the breakfast meal. The clementine was being cut in half and each resident was served half of the small clementine. 2. Staff #5 acknowledged the residents were not provided a serving of fruit during the breakfast meal.
Plan of Correction:	The action plan consists of educating the entire dietary crew on the importance of knowing the appropriate serving amounts of food for each resident. This education will emphasize adherence to the guidelines outlined in the Dietary book in the kitchen and the menu. By ensuring that all staff members understand these standards, we aim to maintain consistency in serving sizes and provide residents with the appropriate nutrition they require. Date Corrected: March 22, 2024