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: April 30, 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 on 4-30-24, two inspectors from the Peninsula Licensing Office. (Ar 07:53/dep 11:57). The facility census was 31. 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 #:	22VAC40-73-320-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the results of a risk assessment documenting the absence of tuberculosis in a communicable form as evidence by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. On 4-30-24, resident #2?s record included two tuberculosis assessments documents. The assessment did not include the date of the assessment. The resident?s date of admit to the facility was noted as 1-10-24. Staff #1 stated resident?s record included an assessment dated March 2024, that document was not in the record reviewed. 2. Staff #1, #2 and #3 acknowledged the resident?s record did not include a TB assessment dated on/or prior to admission.
Plan of Correction:	The corrective action plan regarding the TB assessment form from admission involves addressing a procedural gap identified in our documentation process. It has been observed that the TB assessment, typically included in the Hospital & Provider (H&P) documentation from the hospital, lacks a date indicating when the evaluation was completed. To remedy this oversight, Colonial Manor will initiate the necessary steps to obtain a copy of the TB assessment from the hospice company responsible for the admission. Specifically, we will request the assessment to be conducted on the same date that the resident was admitted to Colonial Manor. Date Corrected: May 15, 2024
Standard #:	22VAC40-73-450-C
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 4-30-24, resident #1?s uniformed assessment instrument (UAI) dated 6-8-23 noted resident was independent for all activities of daily living and ambulation. The ISP received from staff #1, noted on page 1, bathing, mechanical help (mh)-grab bars. Page 2 noted transferring, mh-use or arms of chair and grab bars to transfer and toileting, mh-use of grab bars and a cane to maintain balance while transferring on/off the toilet. Page 3, ambulation: walking, mh- uses a can and hold on grab bars to go around the facility- staff will supervise resident while walking for safety and aid when needed. Stairclimbing, human help & supervision (hh/s)- need help when climbing stairs. Mobility, mh- use can and grab bares when going outside of room. Page 6, orientation, disoriented into some spheres- difficulty with dates and times- did not include what staff should do to assist with dates and times. 2. Resident #2?s record noted resident receives hospice services. According to staff #2 and #3, the resident?s social worker comes and visit. The resident is also receiving nursing services.The nursing and social worker service were not documented on the resident?s ISP dated 2-9-24. The record noted a signed order dated 1-12-24 with a prescribed diabetic/cardiac diet. The ISP noted a cardiac diet. Staff #1 acknowledged these types of special diet are not specifically prepared at the facility. 3. Staff #1, # #2 and #3 acknowledged the residents ISP provided to the inspector on 4-30-24 did not include all assessed needs.
Plan of Correction:	The staff has been informed that the most recent Individualized Service Plan (ISP) and Uniform Assessment Instrument (UAI) are both accessible in the 3C's book. Additionally, the administration will take steps to update the ISP to reflect services included in hospice care and disciplines visiting the residents, such as social workers, chaplains, and nurses. This initiative ensures that our documentation accurately reflects the comprehensive care provided to our residents, including any specialized services and interdisciplinary support. Date Corrected: May 1, 2024