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: 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 on-site NOI monitoring inspection conducted with two licensing inspectors from the Peninsula Licensing Office. Ar (1:45/dep 4:50 p.m.). The 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. 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. 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 or retain individuals with any prohibitive conditions or care needs for one of six residents. Evidence: 1. Resident #1?s Hospice treatment plan and physician?s order dated 3-8-24 documented resident prescribed Haloperidol. Resident?s discharge medication list dated 3-6-24 noted Quetiapine psychotropic medications. The resident?s record did not have documentation of a psychotropic treatment plan. 2. Staff #2 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 #:	22VAC40-73-610-B
Description:	Based on observation and staff interviewed, the facility failed to ensure that the menu for meals and snack for the current week shall be dated and posted in an area conspicuous to residents. Evidence: 1. On 5-9-24, at 12:29 p.m., two inspectors from the Peninsula Licensing Office, observed the facility menu posted was dated May 2 to May 8, 2024. 2. Staff #2 stated not having a key to open the display where the menu and activity calendar is posted. 3. Staff #2 acknowledged the current menu was not posted.
Plan of Correction:	The assigned person (activity coordinator) will be responsible for holding the key to the bulletin board. If she is on vacation, she will give it to the dietary coordinator to post the menu for the week. Date Corrected: May 10, 2024
Standard #:	22VAC40-73-870-E
Description:	Based on observation and staff interviewed, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers was kept clean and in good repair and condition. Evidence: 1. On 5-9-24 during a tour of the facility with staff #3, the bathtub in room #12 was missing tiles on the right side, the lower portion (step entrance) to the tub. The tub was also observed to covered in a greyish colored substance. 2. Staff #3 acknowledged, the bathtub and tile in room #12 was in need of repair and was not cleaned.
Plan of Correction:	Maintenance is currently working on all upgrades and ensuring that every room is inspected. Housekeeping is responsible for reporting any issues observed during their cleaning to management to avoid any delays in construction and repairs. The tub will be reconstructed, and efforts will be made to ensure it remains neat and clean at all times for the residents. Date Corrected: June 20, 2024