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: Sept. 22, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND

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: 09/22/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 08/30/2023 regarding allegations in the area(s) of: Part VI Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 67. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 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 #:	22VAC40-73-680-C
Description:	Based on record review, 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. The August MAR for Resident #1 does not indicate that Resident #1 received their 10pm dose of Ketorolac 0.5% or Prednisolone 1% on 8/7/23.
Plan of Correction:	The ALD/Designee will review Quick Mar reports daily to reconcile for any exceptions, missed medications/ treatments or past due alerts. All medication staff will be trained to review Quick Mar alerts on EMAR at the end of their shift and correct.
Standard #:	22VAC40-73-680-I
Description:	Based on record review, the facility failed to ensure the MAR include specific indications for administering drugs or supplements. Evidence: 1. Resident #1 received the following orders to be administer to their left eye on 7/26/23: 1 drop of Brimonidine 0.2% 2 times daily for 1 week (7/26/23-8/2/23), 1 drop of Ketorolac 0.5% 4 times a day for 5 weeks, 1 drop of Prednisolone acetate 1% 4 times a day for 5 weeks, and 1 drop of Tobramycin 0.3% 4 times a day for 1 week (7/26/23-8/2/23). However, the August 2023 MAR indicates to administer the listed medications to the ?affected eye? with a diagnosis of ?eye,? and does not clarify specifically the left eye for administration.
Plan of Correction:	Neil Pharmacy consulting pharmacist audited all treatment and medication orders on 09/26/23 for specific location. Resident Care Manger has corrected all existing orders for specific areas. 10-5-23 all Medication aid staff will be trained to clarify with ordering MD any treatments/medications without specific areas indicated.