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: May 16, 2023

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

22VAC40-73-1090 22VAC40-73-1140

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/16/2023 from 8:45 am to 3:45 pm. 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: 55 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1110-A
Description:	Based on record review, the facility failed to ensure prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee determine whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident's file. Evidence: 1. Resident #1, Resident #5, and Resident 8 did not have documentation of the determination and justification on whether placement in the special care unit is appropriate by the licensee, administrator, or designee.
Plan of Correction:	The administrator/licensee will document upon admission justification of need for safe secure environment in the resident record.
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 #4 (hire date 12/01/2022) works as direct care staff and does not have documentation of a current certification in first aid in their staff record.
Plan of Correction:	HR director has scheduled a CPR and first aid class through American heart association for 6/2/2023 to address all out of compliance and expiring Assisted Living & Memory Care Associates.
Standard #:	22VAC40-73-290-B
Description:	Based on observation, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge, as provided for in this chapter, in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. Upon entry on 05/16/2023, the posted designated on-site person in charge was Staff #5; however, Staff #5 was not on-site at the facility at that time.
Plan of Correction:	Each day, during change of shift huddle MT in charge will change out sign. Assignment will have 1st floor MT as dedicated person in charge in absence of the administrator.
Standard #:	22VAC40-73-410-A
Description:	Based on record review, the facility failed to ensure upon admission, the assisted living facility provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record. Evidence: 1. Resident #1 (admitted 04/14/2023) and Resident #5 (admitted 04/03/2023) did not have evidence of receiving orientation in their resident records. 2. The documentation of orientation for Resident #2 (admitted 08/03/2022) was not dated.
Plan of Correction:	Upon admission, Memory Care Manger/ Resident Care Coordinator will have orientation form signed and filed in chart. Administrator/designee will audit for form within 24 hours of the admission.
Standard #:	22VAC40-73-450-D
Description:	Based on record review and discussion, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan. Evidence: 1. The ISP for Resident #8 (dated 5/12/2023) indicated the resident was receiving hospice services. There was no other documentation pertaining to the resident being admitted to hospice services in their record. 2. Staff #2 confirmed the resident was admitted to hospice on 05/09/2023 and the facility does not have documentation of an agreed upon coordinated plan of care with hospice for Resident #8.
Plan of Correction:	The Memory care manger/RCC and Resident care manger will request plan of care from admitting hospice company on day of admission.
Standard #:	22VAC40-73-450-E
Description:	Based on record review, the facility failed to ensure the individualized service plan be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. Evidence: 1. The ISP for Resident #4 (completed 4/24/2023) has not been signed or dated by the resident. 2. The ISP for Resident #6 (completed 1/4/2023) was not signed by the licensee, administrator, or their designee, and or the person who has developed the plan.
Plan of Correction:	An audit of all ISP?s will be conducted for completion and signature of residents. By the Assisted Living Director/ Memory Care Manger or designee.
Standard #:	22VAC40-73-490-A
Description:	Based on documentation and discussion, the facility failed to retain a licensed health care professional who has at least two years of experience as a health care professional in an adult residential facility, adult day care center, acute care facility, nursing home, or licensed home care or hospice organization, either by direct employment or on a contractual basis, to provide on-site health care oversight. Evidence: 1. The most recent Health Care Oversight was conducted on 10/28/2022. 2. Staff #2 confirmed the most recent Health Care Oversight was completed on 10/28/2022.
Plan of Correction:	The Memory Care Manager will conduct oversight for the assisted living level of residents. The Assisted Living Director will conduct memory care health care oversight.
Standard #:	22VAC40-73-580-A
Description:	Based on record review, the facility failed to ensure when any portion of an assisted living facility is subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulations, as evidenced by an initial and subsequent annual reports from the Virginia Department of Health. The report shall be retained at the facility for a period of at least two years. Evidence: 1. The last health inspection was completed on 03/24/2022.
Plan of Correction:	Request for inspection will be completed by the dining service director/executive director.
Standard #:	22VAC40-73-610-B
Description:	Based on observation, the facility failed to ensure menus for meals for the current week are dated and posted in an area conspicuous to residents. Evidence: 1. During the tour of the facility on 05/16/2023, the posted menu outside the AL dining room was for the week of May 7, 2023 to May 13, 2023. Additionally, a menu for the current week was not observed to be posted within the safe, secure environment.
Plan of Correction:	Dining Service Director, Dining Room Supervisor and Lead Servers will ensure postings are current and posted in front of the Assisted Living Dining Room and Memory Care Dining Room every Two weeks.
Standard #:	22VAC40-73-680-C
Description:	Based on observation and interview, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: 1. During a medication observation with Staff #6, Resident #5 was administered a Nexium 40 mg capsule at 9:32 am; however, upon review of Resident #5?s physician orders, the order indicates the medication is scheduled to be administered at 6:30 am.
Plan of Correction:	Med tech will have education on 6 rights of medication administration. Consulting Pharmacist will review all standard administration times for the facility for recommendations for early morning medication time corrections.