VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Colonnades
100 Colonnades Hill Drive
Charlottesville, VA 22901
(434) 963-4185

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: June 22, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Census with fire drills/residents

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6-22-2023, 10:40 a.m. ? 1:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 32 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility, medication pass observation, staff interviews, emergency supplies. Number of resident records reviewed: 8 Number of staff records reviewed: 3 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 Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure the person?s physical examination by an independent physician contained the date of the physical examination and the description of the person?s reaction to any known allergies. Evidence: Resident #1 admitted 4-11-2023. Resident #1?s physical examination on file did not contain a date of the physical examination. Additionally, under allergies documented ?sulfas, iodine, shellfish? but no description of reactions to each allergy. Staff #1 confirmed Resident #1?s physical exam did not contain the required information.
Plan of Correction:	(A) On 7/20/23, resident expired at facility from natural causes. (B) On 7/24/23, Administrator and Assisted Living Coordinator audited current resident?s initial physical examination forms to confirm it contained the date/time of the physical examination was completed by an independent physician. On 7/24/23, the Administrator and ALC audited residents with allergies to confirm that reactions are documented on the physical examination form. Issues identified were corrected. (C) On 7/26/23, the RCD/designee provided training to Sales team, Social Worker and Wellness Nurses on the completion of the physical examination form to include the date/time it was signed and known allergies documented have the description of reaction to allergens. (D) Starting on 7/28/23 the RCD/Administrator will audit new move in physical examination form weekly for 3 months to confirm the accuracy of the new move in physical examination and the description of the resident?s reaction to any known allergies. The RCD or designee will report the results of the weekly audits at the Quality Assurance and Performance Improvement Meetings for 3 months. The administrator and or designee is responsible for ensuring implementation and ongoing compliance of this POC and addressing and resolving any variances that may occur.
Standard #:	22VAC40-73-470-D
Description:	Based on record review, the facility failed to implement the written policy to ensure that staff are made aware of allergies and actions that staff may need to take. Evidence: Resident #1?s physical examination contained in the record documented an allergy to shellfish. Resident #1?s Progress Notes dated 6-09-2023 documented, ?Resident mistakenly got some shellfish in a soup but [Resident #1] spit it right out. Then brushed [Resident #1?s] teeth?? The facility?s policy regarding allergies ?Allergies & Life Threatening Conditions? dated 9-27-2019 documented, ?The Dining Service Coordinator (DSC) ensures the following: ?Allergies will be avoided on the service line and appropriate substitutions made.? Staff #1 confirmed during interview that the policy was not followed in regard to the incident concerning Resident #1 on 6-09-2023.
Plan of Correction:	(A) Resident #1 had no negative outcome after getting and spitting out soup that she received that contained shellfish. On 7/26/23, the Administrator and Resident Care Director provided training to the Dining Services Coordinator on assuring residents with food allergies will have appropriate substitution made, this will occur on the service line. (B) On 7/26/23, DSD confirmed resident?s allergies are reflected on the service line and appropriate substitutions are available. (C) On 7/26/23, Dining Services Coordinator initiated an in-service for the dining team on proper identification of resident?s allergies. (D) Starting 7/28/23, the administrator/designee will observe weekly x3 months to confirm that resident?s allergies are avoided on the service line and appropriate substitutions are available. The Administrator or designee will report the results of the weekly audits at the Quality Assurance and Performance Improvement Meetings for 3 months. The administrator is responsible for ensuring implementation and ongoing compliance of this POC and addressing and resolving any variances that may occur.