VIRGINIA DEPARTMENT OF SOCIAL SERVICES

First Colonial Inn ALF
845 First Colonial Road
Virginia beach, VA 23451
(757) 428-2884

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: April 19, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

An unannounced, renewal inspection was conducted by two Licensing Inspectors on 04-19-2022 from 8:30 AM to 3:30 PM. There were 48 residents in care at the time of the inspection. LI reviewed 4 staff records, 8 resident records, and criminal background checks for all new staff since the last inspection. Water temperatures were sampled, emergency supply observed, and medication observations conducted. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. The areas of noncompliance were discussed with the Administrator throughout the inspection and during the exit interview.

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff #1 works as direct care staff and does not have a current certification in first aid. 2. Staff #2 works as direct care staff and has a certification in first aid through National CPR Foundation; however, the certification is not through the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.
Plan of Correction:	Human Resources Director has completed CPR training to be a CPR instructor. Human Resources Director will conduct monthly on-site CPR & First Aide classes to ensure all associates are CPR and First Aide certified starting 06/01/2022. Assisted Living Director & Administrator have contracted with Neil Pharmacy to hold a CPR and First Aide Course on-site to put all out of compliance associates through the course no later than 05/15/2022.
Standard #:	22VAC40-73-260-C
Description:	Based on observation, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR be posted in the facility so that the information is readily available to all staff at all times. Evidence: 1. A listing of all staff who have certification in first aid and/or CPR was posted in the facility; however, it was dated 4/23/21 and not current.
Plan of Correction:	Administrator will communicate with Human Resources Director to ensure that the CPR & First Aide current list in posted in Assisted Living. Human Resources Director will ensure that the list remains current through updating the list monthly or with a change in community staffing starting 04/26/2022.
Standard #:	22VAC40-73-430-H-1
Description:	Based on record review and interview, the facility failed to ensure a dated discharge statement signed by the licensee or administrator that contains the information listed in the standard to be provided to the resident and, as appropriate, his legal representative and designated contact person at the time of discharge. Evidence: 1. The records for Resident #1 and Resident #2 did not contain a written discharge statement. 2. Staff #1 acknowledged Resident #1 and Resident #2 did not have a written discharge statement retained in the resident?s records.
Plan of Correction:	Administrator will ensure that proper discharge statements are completed and kept with the resident?s records going forward. Upon discharge the Assisted Living Director or Designee with submit the discharged resident?s information to the Administrator for completion of the discharge statement within 72 hours of leaving First Colonial Inn.
Standard #:	22VAC40-73-430-H-1
Description:	Based on record review and interview, the facility failed to ensure a dated discharge statement signed by the licensee or administrator that contains the information listed in the standard to be provided to the resident and, as appropriate, his legal representative and designated contact person at the time of discharge. Evidence: 1. The records for Resident #1 and Resident #2 did not contain a written discharge statement. 2. Staff #1 acknowledged Resident #1 and Resident #2 did not have a written discharge statement retained in the resident?s records.
Plan of Correction:	Administrator will ensure that proper discharge statements are completed and kept with the resident?s records going forward. Upon discharge the Assisted Living Director or Designee with submit the discharged resident?s information to the Administrator for completion of the discharge statement within 72 hours of leaving First Colonial Inn.
Standard #:	22VAC40-73-440-D
Description:	Based on record review, the facility failed to ensure that the uniform assessment instrument (UAI) is completed as required by 22VAC30-110. Evidence: 1. The UAI for Resident #4 (dated 12/7/21) was not signed for approval by the administrator or designee. 2. The level of care approved on the UAI for Resident #5 (dated 1/18/22) was not marked for either residential living or assisted living.
Plan of Correction:	Assisted Living Director and Administrator will ensure that all UAI?s are reviewed and signed for approval. Random audits of the UAI?s and ISP?s will be conducted monthly to ensure that all appropriate boxes are checked going forward. UAI for Resident #4 was immediately corrected to indicate appropriate living classification as of 04/26/2022.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the Individualized Service Plan (ISP) included a description of the resident?s identified needs based on the Uniform Assessment Instrument (UAI). Evidence: 1. The expected outcomes and time frame of Resident #4?s ISP (dated 12/20/21) is dated 1/20/21 and does not include date outcome achieved for the identified needs. Additionally, Resident #4?s UAI (dated 12/7/21) states the resident requires supervision with toileting and walking; however, Resident #4?s ISP indicates the resident requires mechanical and supervision assistance with toileting and walking. The UAI for Resident #4 also indicates the resident requires mechanical and physical assistance with transferring; however, Resident #4?s ISP states the resident requires only mechanical assistance with transferring. 2. Resident #6?s ISP (dated 2/22/22) does not include date outcome achieved for the following identified needs: code status, allergies, and bathing. Resident #6?s ISP also does not address the resident?s bladder incontinence of less than weekly as identified on Resident #6?s UAI dated 2/22/22.
Plan of Correction:	Administrator and Executive Director will complete ISP training no later than 05/30/2022. Assisted Living Director and Administrator reviewed Resident #4?s ISP and the ISP has been corrected with the appropriate outcome dates 04/26/2022. Resident #6?s UAI/ISP will be audited to ensure all appropriate outcome dates are present 04/26/2022. Moving forward Assisted Living Director and Administrator will conduct UAI/ISP audits on all residents to ensure that all identified needs on the UAI are properly correlated with the ISP. This will take place no later than 05/30-2022.
Standard #:	22VAC40-73-970-A
Description:	Based on record review, the facility failed to ensure fire and emergency evacuation drill frequency and participation be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month. Evidence: 1. Upon review of documentation, no fire drills were conducted in 8/2021, 12/2021, and 2/2022. The documentation also indicates fire drills conducted on 9/30/21 and 10/28/21 were conducted around 2 pm with the first shift.
Plan of Correction:	Executive Director and Administrator met with the Environmental Services Director on 04/26/2022 to review the Virginia Regulations to express the importance of conducting monthly fire drills with alternating shift times reflective of Assisted Living Staffing schedule each quarter. Fire drills will be conducted monthly beginning 05/01/2022 and ongoing with alternating shift times each quarter. Going forward the Environmental Services Director will keep an Emergency Drill Log to ensure that drills are conducted on appropriate shifts.
Standard #:	22VAC40-73-980-H
Description:	Based on observation, the facility failed to ensure the availability of a 96-hour supply of emergency food and drinking water with at least 48 hours of the supply on site. Evidence: 1. The emergency food supply reviewed with Staff #7 included beef ravioli that expired on 01/04/22. There were also at least two cans of chicken noodle soup that expired 02/16/22. The availability of unexpired items in the emergency food supply was not enough to serve 48 residents for 96 hours.
Plan of Correction:	Executive Director and Dining Services Director will ensure that at least 48 hours of drinking water and adequate food supply are on site by 05/01/2022. Dining Services Director and Chef du Cuisine will ensure that the food supply and drinking water are properly rotated in/out to ensure that expiration dates are observed, and more are ordered as needed. Contract for emergency food and drinking water will be updated and provided to Administrator to be stored in the 2022 DSS binder.
Standard #:	22VAC40-73-990-C
Description:	Based on interview, the facility failed to document that staff participated in practice exercises for resident emergencies at least once every six months. Evidence: 1. The facility could not provide documentation that staff had participated in an exercise in which the procedures for resident emergencies were practiced at least every six months.
Plan of Correction:	Assisted Living Director held a training for Assisted Living staff on 04/20/2022 with the Administrator present and reviewed resident emergencies including missing resident, fire emergencies, choking, and finding an unresponsive resident. Elopement drill will be conducted 04/29/2022 and every six months thereafter. Resident emergencies Drill and Training will be conducted at a minimum every six months. Next training will be held on 05/18/2022 for all associates on all shifts.