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: June 5, 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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring An unannounced monitoring training was conducted on 6-5-24 with two inspectors from the Peninsula Licensing Office. (Ar 08:20 a.m./Dep 14:00). 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 #:	22VAC40-73-250-D
Description:	Based on record reviewed, the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents shall submit the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. On 6-5-24, staff #4?s TB document in the record was dated 5-1-24. The staff?s date of hire was noted as 4-1-24. 2. Staff #1 and #3 acknowledged the staffs? TB was not completed on/or prior to the date of hire.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-290-A
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the written work schedule was current. Evidence: 1. On 6-5-24, the housekeeping and maintenance scheduled posted in the staff break room was dated March 4 to May 4, 2024. 2. Staff # 2 acknowledged the aforementioned staff scheduled posted was not current.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 two of three records reviewed. Evidence: 1. Resident #1?s June 2024 medication administration record (MAR) and physician?s orders dated 5-1-24 noted resident prescribed Olanzapine (6-16-18) and Valproic Acid (6-10-23). The record did not have documentation for the prescribed psychotropic medications being administered. 2. Resident #2?s June 2024 MAR and physician?s orders dated 5-1-24 noted resident prescribed (Sertraline10-17-23) and Lorazepam (6-3-24). The record did not have documentation for the prescribed psychotropic medication. 3. Staff #1 and # 2 acknowledged during exit meeting the resident?s record did not contain a treatment plan for the prescribed psychotropic medication.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure the resident?s individualized service plan (ISP) addressed all assessed needs. Evidence: 1. On 6-5-24, resident #1?s uniformed assessment instrument (UAI) dated 5-1-24, noted resident?s behavior is appropriate. The ISP dated 5-1-24 noted resident staff is to provide intervention when resident becomes agitated. The resident was observed being given Lamisil fungal cream during the medication pass to self-administer. The UAI noted resident?s medication is to be administered by staff. The record did not have an order resident to self-administer this medication. 2. Resident #3?s UAI dated 5-1-24 noted resident behavior assessed as appropriate. The ISP dated 5-6-24 noted resident is to be redirected and provided activity when resident becomes agitated. 3. Staff #1 and #2 acknowledged the residents UAI did not include the assessed needs noted on the ISPs.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-I
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure medication administration record included all requirements. Evidence: 1. On 6-5-24, resident #1?s June 2024 medication administration record (MAR) was observed with missing staff initials on 6-2-24 for Valproic Acid (8:00 p.m.); Ensure (8:00 p.m.) and Mirtazapine (8:00 p.m.). 2. Resident #3?s June 2024 MAR missing staff initials on 6-2-24 for Phenobarbital (8:00 p.m.) and Refresh tears (8:00 p.m.). 3. Staff #1 and #2 acknowledged the residents? MARs did not have the initial of staff on the dates.
Plan of Correction:	Not available online. Contact Inspector for more information.