VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: April 15, 2025 and April 21, 2025

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:

22VAC40-73-50 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:

Standard #:	22VAC40-73-200-D
Description:	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: 1. 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. 2. 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.
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 #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.
Standard #:	22VAC40-73-310-D
Description:	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: 1. There was no evidence written assurance was provided to Resident #6 (admitted 02/26/2025) or their legal representative in the resident?s record. 2. 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.
Standard #:	22VAC40-73-350-B
Description:	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: 1. 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.
Standard #:	22VAC40-73-490-A
Description:	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: 1. The last health care oversight was completed on 10/02/2024 and included a review of 18 resident charts. 2. 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.
Standard #:	22VAC40-73-550-G
Description:	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: 1. 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. 2. 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.