First Colonial Inn ALF — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

First Colonial Inn ALF was inspected 11 times between May 10, 2021 and May 27, 2026 by the Virginia Department of Social Services. 8 of those visits ended with violations cited and 3 with none. Across that history VDSS cited 40 violations under 32 distinct standards. 1 inspection was prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 10 of these 11 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type

Assisted Living Facility

License type

Two Year

License expires

06/30/2026

Licensing inspector

Donesia Peoples

Inspector phone

757 353-0430

Approved for

Assisted Living · Ambulatory Only · Special Care Unit

Inspection History

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

May 27, 2026Inspection5 violations

Inspection dates

05/27/2026, 06/02/2026

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE

Technical assistance

22VAC40-73-220

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: An unannounced renewal inspection took place on 05/27/2026 at 8:08 am to 4:35 pm and 06/02/2026 at 12:40 pm to 1:43 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: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 6 Observations by licensing inspector: Breakfast, and an activity were observed. A medication pass observation was completed for three residents. The following were reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored Additional Comments/Discussion: None 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-150-B

Based on staff interviews the facility failed to ensure If an administrator dies, resigns, is discharged, or becomes unable to perform his duties, the facility shall immediately employ a new administrator or appoint a qualified acting administrator so that no lapse in administrator coverage occurs. For a facility licensed for both residential and assisted living care, the facility shall immediately notify the Virginia Board of Long-Term Care Administrators and the department's regional licensing office that the licensed administrator died, resigned, was discharged, or became unable to perform his duties and that a new licensed administrator has been employed or that the facility is operating without an administrator licensed by the Virginia Board of Long-Term Administrators, whichever is the case, and provide the last date of employment of the previous licensed administrator.

Evidence

During an interview on 05/26/2026 with staff #5, staff #5 notified the Licensing Inspector (LI) the facility does not have an administrator licensed and or authorized by the Virginia Board of Long-Term Care Administrators employed at the facility. Staff #5 stated the last day of the previous administrator employed with the facility was 04/15/2025. Staff #5 confirmed the facility has not had an administrator employed at the facility since 04/15/2025 and the following notifications were not sent on behalf of the facility: • a notification was not sent to the department’s regional licensing office nor the Virginia Board of Long-term Administrators of the administrator last day of 04/15/2025 • a notification of the facility operating without an administrator licensed by the Virginia Board of Long-Term Administrators after 04/15/2025.

Plan of correction

AED (Assistant Executive Director) and CSD (Community Services Director) to start AIT (Administrator in Training) program and complete required hours. AED has 320 hours to complete, CSD has 480 hours to complete. Applications to be submitted for review and acceptance by 6/28/26

22VAC40-73-190-C

Based on the record review and staff interview the facility failed to ensure prior to being placed in charge, the staff member shall be informed of and receive training on his duties and responsibilities and provided written documentation of such duties and responsibilities.

Evidence

The Staff Person in Charge posting located on the first floor of the facility on 05/27/26 at 8:17 am listed staff #1 as the staff person in charge.
Upon request, and during an interview on 05/27/26 with staff #6, staff #6 was not able to provide documentation of staff #1 receiving written documentation of the duties and responsibilities of being the staff person in charge. Photographic evidence is available.

Plan of correction

1. All current Staff Persons in Charge have been identified and provided with updated written documentation outlining their duties and responsibilities in compliance with 22VAC40-73-190-C. 2.Staff #1 and all identified SPIC-eligible staff have completed a review and acknowledgment of the SPIC duties and responsibilities document. Signed acknowledgments are on file. 3.The CSD (Care Services Director) has verified and second-checked all SPIC assignment records and documentation. The RCM cross-references SPIC postings against written documentation on a daily basis. 4.Going forward, no staff member will be assigned or posted as the Staff Person in Charge without first receiving, reading, and signing the SPIC responsibilities document. This process is documented in the daily charge assignment log. 5.Ongoing monitoring: The Director of Care Services will conduct weekly audits of SPIC postings and corresponding documentation files for a period of 90 days.

22VAC40-73-320-A

Based on the record review and staff interview the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following: Results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it Evidence:
The record for resident #4, admission date 05/05/25, contains a physical exam and results of a TB assessment completed 12/11/24, more than 30 days prior to the resident’s admission.
Upon request, and during an interview on 05/27/26 with staff #6, staff #6 was not able to provide a physical examination and a TB assessment completed within 30 days prior to resident #4’s admission and staff #6 confirmed the resident’s physical exam and assessment for TB is dated as completed on 12/11/24.

Plan of correction

Care Services Director to review H&P and TB screening form prior to admission to ensure completion of form is within 30days of admission, to be confirmed by second check performed by Resident Care Manager.

22VAC40-73-450-C

Based on the record review and staff interview the facility failed to ensure the comprehensive individualized service plan (ISP) shall include a description of identified needs and date identified based upon the UAI and other sources.

Evidence

The record for resident #2, contains the following: • a UAI that documents need of mechanical & human help (physical assistance) for bathing and mechanical & human help (supervision) for dressing. • A Do Not Resuscitate Order (DNR) dated 01/28/25. Resident #2’s ISP dated 02/06/26 does not include the resident’s needs for physical assistance for bathing and supervision for dressing. The ISP documents the resident is a Full Code and does not include the resident’s DNR Status.
During an interview on 05/27/26 with staff #6, staff #6 reviewed the UAI and ISP for resident #2 and confirmed the ISP did not include the resident’s needs for physical assistance with bathing, supervision with dressing, and the resident’s DNR status.
The record for resident #3 contains a DNR order dated 08/08/25. The resident’s ISP dated 04/06/26 does not include the resident’s DNR status.

Plan of correction

1.The RCM has been directed to immediately review and update the ISPs for Resident #2 and Resident #3 to include all required elements: physical assistance needs for bathing, dressing, and supervision; DNR status as documented by the independent physician; and UAI-identified services with dates. 2.The RCM has completed a full ISP audit across all current residents' records, comparing ISP contents against the UAI, physician orders, and clinical documentation to ensure accuracy and completeness. 3.CSD Code Status and DNR documentation have been added to the ISP template as a mandatory section. All staff responsible for ISP completion have been retrained on the requirement to cross-reference the UAI and physician orders when completing or updating ISPs. 4.A second-check process has been implemented: the CSD will review and countersign all ISPs within 48 hours of completion or update. ISPs will be compared against the resident's UAI and current physician orders before finalization. 5.Ongoing monitoring: Monthly ISP audits will be conducted by the RCM with secondary review by the Care Services Director to verify completeness and consistency with current resident needs.

22VAC40-73-640-A

Based on observation and review of the facility’s medication management plan the facility failed to implement a written plan for medication management to include methods to prevent the use of contaminated medications.

Evidence

The facility’s medication management plan dated 12/05/25 documents the following: • If a medication is contaminated such as being dropped) dispose of the contaminated medication and use the next available dose.
During the medication pass observation on 05/27/26 at 8:28 am with staff #1, the Licensing Inspector (LI) observed staff #1 administering medications to resident #6. During the observation one of the resident’s medication tablet dropped on the floor. Staff #1 then picked the tablet off the floor and proceeded to administer the tablet to the resident.
During an interview on 05/27/26 with staff #1, staff 1 stated staff #1 was not sure of the facility’s policy regarding what to do when a resident’s medication drops on the floor. Staff #1 stated staff #1 received training on the facility’s medication management plan within the last year.

Plan of correction

The medication aide involved was immediately re-educated on the facility’s medication management plan and instructed that any medication that is dropped, damaged, outdated, or otherwise contaminated must not be administered and must be disposed of according to the facility’s medication disposal procedure. The CSD/designee will re-educate all staff who administer medications on 22VAC40-73-640-A-3, the facility’s medication management plan, and the requirement to prevent the use of contaminated medications. Staff will sign an acknowledgment of training. The CSD/designee will conduct direct medication pass observations weekly for four weeks and monthly for three months to verify compliance. Any identified concern will be corrected immediately through coaching and retraining. The CSD is responsible for implementation and ongoing monitoring.

April 15, 2025Inspection6 violations

Inspection dates

04/15/2025, 04/21/2025

Areas reviewed

Technical assistance

22VAC40-73-50 22VAC40-73-450

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: 04/15/2025 from 8:15 am to 2:45 pm and 04/21/2025 from 12:00 pm to 12:42 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: 71 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 4 residents. The following were reviewed: resident and staff records, medication carts, call bells, and water temperatures. 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

22VAC40-73-310-D

Based on record review and interview, the facility failed to provide written assurance to a resident or the legal representative documenting that the facility has the appropriate license to meet their care needs at the time of admission. Copies of the written assurance shall be given to the legal representative and case manager, if any, and a copy signed by the resident or their legal representative shall be kept in the resident's record.

Evidence

There was no evidence written assurance was provided to Resident #6 (admitted 02/26/2025) or their legal representative in the resident’s record.
Staff #2 confirmed Resident #6’s record did not include documentation of written assurance.

Plan of correction

Letter of Written Assurance has been obtained and signed by Resident #6 as of 4.29.2025. The Hospitality Services manager will ensure these are completed and signed prior to admission. The Assistant Executive Director will audit all admission files prior to admission to ensure admission requirements are met.

22VAC40-73-260-A

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

Staff #5 (hired 09/27/2017) work as direct care staff and did not have a current certification in first aid in their staff record during the onsite inspection on 04/15/2025.

Plan of correction

Staff #5 has fulfilled the CPR requirement, and a copy of their card has been placed in their file. The facility will ensure that CPR compliance is maintained on all direct staff based on a monthly audit completed by our Human Resources Generalist.

22VAC40-73-350-B

Based on record review, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and failed to document that this was ascertained and the date the information was obtained.

Evidence

The sex offender screening for Resident #6 (admitted 02/26/2025) was completed on 04/15/2025.

Plan of correction

Sex Offender Check has been obtained for Resident #6 as of 4.15.2025. The Hospitality Services Manager will ensure these are completed prior to admission. The Assistant Executive Director will audit all admission files prior to admission to ensure admission requirements are met.

22VAC40-73-550-G

Based on record review and interview, the facility failed to annually review the rights and responsibilities of residents with each resident, or their legal representative or responsible individual as stipulated in subsection H of this section.

Evidence

The records of Resident #3, Resident #4, and Resident #5 did not include a current written acknowledgement of having been so informed of the review of the rights and responsibilities of residents within the last year.
Staff #2 confirmed the facility was unable to locate the annual review of rights and responsibilities of residents for Resident #3, Resident #4, and Resident #5.

Plan of correction

Resident Rights will be signed by Resident #3, #4, and #5 and filled in charts by May 1, 2025. Resident Rights will be signed by all residents annually in May of each year and coordinated by the Care Services Director to ensure all residents or responsible parties have signed and they are filled in charts accordingly.

22VAC40-73-490-A

Based on record review, the facility failed a licensed health care professional, practicing within the scope of the health care professional’s profession, provide health care oversight at least every six months, or more often if indicated, based on the health care professional’s professional judgment of the seriousness of a resident's needs or stability of a resident's condition for residents who meet the criteria for assisted living care. All residents shall be included at least annually in health care oversight.

Evidence

The last health care oversight was completed on 10/02/2024 and included a review of 18 resident charts.
There was no evidence to support all residents within the assisted living have been included in the health care oversight within the last 12 months.

Plan of correction

The Health Care oversight will be scheduled every 6 months with our Care operations Director and coordinated by our Care Services Director. Next Health Care Oversight scheduled for May 7, 2025.

22VAC40-73-200-D

Based on record review and interview, the facility failed to obtain a copy of the certificate issued or other documentation indicating that the person has met one of the requirements of subsection C of this section, which shall be part of the staff member's record in accordance with 22VAC40-73-250.

Evidence

The record for Staff #3 (hired 01/16/2025) did not include a copy of the certificate issued or other documentation indicating that Staff #3 has met one of the requirements of subsection C of this section.
Staff #2 was unable to provide a copy of the certificate issued or other documentation indicating that Staff #3 has met one of the requirements of subsection C of this section during the onsite inspection on 04/15/2025.

Plan of correction

Staff #3 has provided a copy of proof that they completed their certified nursing assistance course as of June 4, 1996, this documentation has been added to their file. The facility will ensure these requirements are met prior to employment for all associates.

January 27, 2025Complaint survey0 violations

Inspection dates

01/27/2025

Areas reviewed

22VAC40-73 BUILDINGS AND GROUND

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/27/2025 from 12:35 pm to 12:50 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/17/2025 regarding allegations in the area(s) of: Buildings and Grounds. Number of residents present at the facility at the beginning of the inspection: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

May 21, 2024Inspection3 violations

Inspection dates

05/21/2024

Areas reviewed

Technical assistance

22VAC40-73-290

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: 05/21/2024 from 8:45 am to 2:45 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: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 4 residents. The following were reviewed: resident and staff records, medication carts, call bells, and water temperatures. 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

22VAC40-73-410-A

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

Resident #7 (admitted 06/07/2023) did not have evidence of receiving orientation in their resident records.

Plan of correction

Orientation will be completed by the resident care manager/memory care manager on the day of admission. The Assistant Living Director will be audited for completion on the day of admission.

22VAC40-73-1100-A

Based on record review, the facility failed to obtain the written approval of one of the following persons listed in the standard of placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment.

Evidence

Resident #6 (admitted 07/31/2023) and Resident #7 (admitted 06/10/2023) did not have documentation of approval for placement in a special care unit in the resident’s record.

Plan of correction

Approval for placement form will be audited 24 hours prior to admission to ensure proper documentation is completed. Signed Approval for placements copies will be placed in the Care Chart and attached. Electronically to the resident profile original well remain in the Resident Relation File.

22VAC40-73-320-A

Based on record review, the facility failed to ensure the physical examination include a statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H.

Evidence

The admitting physical examination for Resident #1, Resident #2, Resident #4, Resident #5, Resident #6, and Resident #7 did not include a statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H.

Plan of correction

The physical examination form has been updated to include a statement. The individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H.

September 22, 2023Inspection2 violations

Inspection dates

09/22/2023

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 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

22VAC40-73-680-C

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

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.

22VAC40-73-680-I

Based on record review, the facility failed to ensure the MAR include specific indications for administering drugs or supplements.

Evidence

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.

September 22, 2023Inspection0 violations

Inspection dates

09/22/2023

Areas reviewed

22VAC40-73 BUILDINGS AND GROUND

Comments

Type of inspection: Other 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. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Observations by licensing inspector: LI and LA inspected 8 additional apartments for license modification request. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 20, 2023Inspection1 violation

Inspection dates

06/20/2023

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 06/20/2023 from 1:15 pm to 2:15 pm. 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 06/01/2023 regarding allegations in the area(s) of: Part III Personnel. Number of residents present at the facility at the beginning of the inspection: 57 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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

22VAC40-73-110-1

Based on record review and interview, the facility failed to ensure that the staff be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged.

Evidence

Resident #1 was noted to have discoloration to right upper arm and left hand in addition to a small skin tear to right wrist on 05/31/2023.
Upon investigation of the origin of these injuries, Staff #3 stated that on the evening of 05/30/2023 while assisting Resident #1 from another resident’s bed, the resident became combative, and Staff #3 had to stop the resident from sliding on the floor. Staff #4 confirmed Staff #3 had to “grab” the resident to prevent the resident from sliding to the floor. Neither Staff #3 or Staff #4 documented or reported this incident.
Staff #1 acknowledged Staff #3 and Staff #4 were not considerate and respectful of the rights, dignity, and sensitivities of Resident #1.

Plan of correction

Staff #3 was terminated. Staff in serviced to the Abuse and Neglect Policy.

May 16, 2023Inspection10 violations

Inspection dates

05/16/2023

Areas reviewed

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

22VAC40-73-450-D

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

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.
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.

22VAC40-73-1110-A

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

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.

22VAC40-73-290-B

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

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.

22VAC40-73-610-B

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

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.

22VAC40-73-580-A

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

Evidence

d 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:
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.

22VAC40-73-410-A

Evidence

Resident #1 (admitted 04/14/2023) and Resident #5 (admitted 04/03/2023) did not have evidence of receiving orientation in their resident records.
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.

22VAC40-73-680-C

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

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.

22VAC40-73-260-A

Evidence

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.

22VAC40-73-490-A

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

The most recent Health Care Oversight was conducted on 10/28/2022.
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.

22VAC40-73-450-E

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

The ISP for Resident #4 (completed 4/24/2023) has not been signed or dated by the resident.
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.

March 10, 2023Inspection0 violations

Inspection dates

03/10/2023

Areas reviewed

22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Technical assistance

Part IX Emergency Preparedness

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: 3/10/2023 from 12:00 pm to 12:50 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Observations by licensing inspector: LI and LA inspected the newly renovated safe, secure environment. Additional Comments/Discussion: Article 3: Safe, Secure Environment standards reviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

April 19, 2022Inspection9 violations

Inspection dates

04/19/2022

Areas reviewed

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

22VAC40-73-980-H

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

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.

22VAC40-73-970-A

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

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.

22VAC40-73-450-C

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

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.
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.

22VAC40-73-260-C

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

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.

22VAC40-73-440-D

Based on record review, the facility failed to ensure that the uniform assessment instrument (UAI) is completed as required by 22VAC30-110.

Evidence

The UAI for Resident #4 (dated 12/7/21) was not signed for approval by the administrator or designee.
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.

22VAC40-73-260-A

Evidence

Staff #1 works as direct care staff and does not have a current certification in first aid.
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.

22VAC40-73-430-H-1

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

The records for Resident #1 and Resident #2 did not contain a written discharge statement.
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.

22VAC40-73-990-C

Based on interview, the facility failed to document that staff participated in practice exercises for resident emergencies at least once every six months.

Evidence

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.

22VAC40-73-430-H-1

Evidence

The records for Resident #1 and Resident #2 did not contain a written discharge statement.
Staff #1 acknowledged Resident #1 and Resident #2 did not have a written discharge statement retained in the resident’s records.

Plan of correction

May 10, 2021Inspection4 violations

Inspection dates

May 10, 2021 , May 12, 2021 , May 13, 2021 and May 17, 2021

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 EMERGENCY PREPAREDNESS

Comments

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 05-10-2021 and concluded on 05-17-2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 62. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, criminal background checks and sworn disclosures of newly hired staff, staff schedules, fire drills, fire and health inspection reports, dietary oversight, and healthcare oversight. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations

22VAC40-73-650-B

Based on record review and interview, the facility failed to ensure prescriber’s orders, both written and oral, for administration of all prescription and over-the-counter medications, identified the diagnosis or specific indications for administering each drug.

Evidence

Resident #1’s signed physician’s orders dated 03-19-2021 did not include a diagnosis or specific indications for Ditiazem 240mg; Tylenol w/Codeine 300-30mg; Robaxin 500mg; Butrans Transdermal patch 15 mcg/hr; Docusate 100mg; Flor-Con 10 MEQ; Soothe XP Opth Soln; Nitroglycerin Sublingual Tab 0.4mg; Omeprazole 40mg; Prednisone 5mg; Melatonin 5mg; and Lasix 20mg.
Staff #1 acknowledged resident #1’s aforementioned orders did not include the diagnosis or specific indications for administering the medications.

Plan of correction

Resident #1 Signed physician’s orders will have diagnosis approved a transcribed to EMAR for Diltiazem 240mg, Tylenol with Codeine 3---30mg, Robaxin 500mg, Butrans Transdermal patch 15mcg/hr., Docusate 100mg, Flor-Con10meq, Soothe XP ophthalmic solution, Nitroglycerin Sublingual tablets, Omeprazole 40mg, Prednisone 5mg, Melatonin 5mg, Lasix 20mg -prescriber notified diagnosis obtained during review. Staff will fulfill regulation as it pertains to ensuring prescribers orders both written and oral, identify the diagnosis or specific indication for administering the drug. RCS, ALD or designee will review all new orders daily to ensure continued compliance. RCS/ALD will audit all records to ensure that all RX, OTC identify the diagnosis condition or specific indication for usage.

22VAC40-73-650-C

Based on record review and interview, the facility failed to ensure the physician's oral orders are reviewed and signed by a physician within 14 days.

Evidence

The following physician’s oral orders were not reviewed and signed by a physician within the required timeframe: A. Resident #1’s orders dated 03-20-2021 for 2L of continuous oxygen, and 03-24-2021 for Tylenol Arthritis Strength 650mg were not reviewed and signed by a physician as of 05-17-2021. B. Resident #4’s orders for Tramadol 50mg (order dated 02-21-2021); Calmoseptine Ointment (order dated 03-03-2021); Immodium 2mg and Floraster 250mg (orders dated 03-05-2021); Triad paste (order dated 04-02-2021); and Triamcinolone 0.1% cream (order dated 04-18-2021) were not reviewed and signed by a physician as of 05-17-2021.
Staff #1 did not provide documentation of a physician’s signature within 14 days for the aforementioned oral orders.
Staff #1 acknowledged the aforementioned oral orders were not reviewed and signed by a physician within the required timeframe.

Plan of correction

Residents #1 & # 4- All telephone orders written by Hospice nurse will be reviewed and signed by Hospice Physician. Staff will fulfill the regulation as it pertains to ensuring oral orders are reviewed and signed by physician within 14 days. ALD, RCS or designee will ensure Hospice nurse will flag new orders written at each visit for review. ALD RCS will review all oral orders and fax to physician within 24 hours for review and signature. RCS or designee will audit current records to ensure compliance.

22VAC40-73-650-F

Based on record review and interview, the facility failed to ensure whenever a resident is admitted to a hospital for treatment, new orders are obtained for all medications prior to or at the time of return to the facility. The facility did not document any contact with the physician regarding the new orders.

Evidence

Resident #2’s hospital “Discharge Summary” dated 03-19-2021, instructed to start Cefdinir (Omnicef) 300mg.
Staff #2 stated the facility “did not obtain” new orders for resident #2’s aforementioned medication prior to or at the time the resident returned to the facility on 03-19-2021.
Resident #3’s hospital “Discharge Summary Notes” dated 04-17-2021, instructed to start Amoxicillin-clavulanate (Augmentin) 75-125mg and Lactobacillus Acidophilus 1 billion.
Staff #2 stated the facility “only obtained orders from hospital” and did not obtain new orders for resident #3’s aforementioned medications prior to or at the time the resident returned to the facility on 04-17-2021.
Staff #2 did not provide documentation of contact made to resident #2 and resident #3’s primary physicians regarding the aforementioned new orders prior to or at the time of the resident’s return to the facility.
Staff #1 and staff #2 acknowledged the facility did not obtain nor notify resident #2 and resident #3’s primary physicians of the new aforementioned medication orders prior to or at the time of the residents return to the facility.

Plan of correction

Resident #2 & 3 ? orders were confirmed and reconciled by PCP as of 5/25/21. Staff will fulfill the regulation as it pertains to hospital returns to the facility that all new medication /treatment orders will be obtained prior to or at the time of return to facility. All orders coming from hospital will be sent to physician prior to or at time of admission and confirmed through documentation of notification as well as any changes. RCS/ALD will review for completeness. All staff who perform charge positions will be trained on the process. Random audits will be performed by Resident Care Supervisor/ALD or designee to ensure compliance.

22VAC40-73-680-D

Based on record review and interview, the facility failed to administer medications in accordance with the physician's instructions. 1. Resident #3’s signed physician’s orders from the hospital dated 04-17-2021 documented ?Amoxicillin-Clavulanate (Augmentin) - Take 1 tab by mouth every 12 hours for 7 days. Qty: 14 tab.? 2. Resident #3’s April 2021 Medication Administration Record (MAR) documented staff administered Amox/K Clav 875- 125 twice daily on 04-18-2021 through 04-23-2021, and one dose in the morning on 04-24-2021. The resident did not receive the last evening dose of Amox/K Clav 875-125 on 04-24-2021. 3. Staff #1 and staff #2 could not provide documentation that the last dose of Amox/K Clav 875-125 was administered to resident #3. 4. Resident #4’s signed physician’s order dated 04-07-2021 documented ?Nystatin Cream 100,000 u/gm- Apply topically to mid and right chest rash BID [twice a day] x 14d for Candidiasis.? 5. Resident #4’s April 2021 MAR documented staff administered Nystatin cream 100,000 twice daily for 15 days on 04- 08-2021 through 04-22-2021. 6. Staff #1 and staff #2 acknowledged the aforementioned medications for resident #3 and resident #4 were not administered in accordance with the physician’s instructions.

Plan of correction

Resident # 3 Augmentin - After further interview with team by recently hired ALD revealed that resident had received first dose of Augmentin prior to being discharged. Staff will fulfill the regulation as it pertains to administration of medication accordance to physicians? instructions. All medication orders will be reviewed and reconciled to EMAR with 24 hours of new orders by RCS or designee for accuracy. RMAs will be re-educated on the 5 rights of medication administration. RCS/ALD or designee will audit all current physician’s orders to ensure orders are reviewed and appropriate to the orders given.