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: May 9, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint An on-site complaint inspection conducted by two inspectors from the Peninsula Licensing Office on 5-9-24 (Ar 12:27 p.m./dep 13:45 p.m.). The administrator was not present. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 4-29-24 regarding allegations in the areas of resident supervision. Number of residents present at the facility at the beginning of the inspection: 31 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: Number of interviews conducted with residents: Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on interview, the facility failed to ensure it reported to the licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health or safety, or welfare of any resident. Evidence: 1. On 5-9-24, during a complaint inspection, staff #2 stated the facility was required to report all incidents to the licensing office. A copy of the facility?s incident reporting policy was reviewed. 2. Staff did not report the police coming to the facility on 4-28-24 regarding resident #1 wandering to a residence in the neighborhood nearby. Staff #1 speaking with the police but did not contact the licensing office to report this incident. 3. Staff #1 acknowledged the facility did not notify the licensing office of an incident involving resident #1 on April 28, 2024.
Plan of Correction:	The incident reporting policy has been reviewed with all staff members, who have read and acknowledged it to reiterate the importance of reporting incidents to the administration. It is mandatory for incidents to be charted in the computer charting system, which prompts an email notification to the administration. Date Corrected: May 15, 2024
Standard #:	22VAC40-73-310-H
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions or care needs for a resident. Evidence: 1. On 5-9-24, resident #1?s record did not have documentation of a psychotropic treatment plan for medications prescribed 4-26-24, Quetiapine Fumarate, Benztropine, Divalproex and Inderal. 2. Staff #2 and #3 acknowledged during exit meeting the resident?s record did not contain a treatment plan for prescribed psychotropic medication.
Plan of Correction:	A treatment plan has been developed for all the listed psychotropic drugs prescribed by the hospice physician. The administration has created a binder that includes the updated plan and arranged it alphabetically to facilitate easy review of additional documents. Date Corrected: June 15, 2024
Standard #:	22VAC40-73-460-D
Complaint related:	Yes
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure provide supervision to a resident?s schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises. Evidence: 1. On 4-28-24, resident #1 wandered to a nearby home. The facility staff # 4 received a call informing that resident was on the caller?s property. Staff went and assisted resident #1 back to the facility. The police later came to the facility and spoke with staff #4 who contacted staff #1. Resident #1?s record noted resident?s absence from the facility and return by staff #4. 2. Resident #1?s uniform assessment instrument (UAI) dated 11-7-23 noted the resident had no behavioral needs. The individualized service plan (ISP) dated 9-8-23 noted resident?s ?occasional wandering outside the facility, walking in the parking lot to exercise?. The resident?s record noted other incidents of wandering into the community, 10-7-23. Facility was notified by the local community behavioral agency of resident being in community. On 11-14-23 resident was observed by staff #2 walking down the road in the community. 3. Staff #2 stated the resident was to be monitored by staff, check for meals and hourly checks. This information was not documented on the resident?s ISP. 4. Interviews with other staff members, staff not aware of resident?s ISP and wandering or frequent checks on resident.
Plan of Correction:	An updated treatment plan and instructions on how to handle instances when a resident acts up have been added to the Individualized Service Plan (ISP). Medications have been revisited to align with resident's mental and behavioral conditions. Additionally, the ISP has been posted in the computer charting record for the staff to review. Date Corrected: May 10, 2024