1 Inspection Summary
Inspection Reports Summary
Covers 11 inspections · May 2021 – May 2026Visit Reason
This report covers 11 inspections of First Colonial Inn ALF from May 10, 2021 to May 27, 2026, including routine, monitoring, renewal, and complaint investigations.
Complaint Details
One complaint survey was conducted on 2025-01-27 regarding Buildings and Grounds. The investigation found no violations of standards or law.
Findings
Across that history VDSS cited 40 violations under 32 distinct standards. 8 of 11 visits ended with violations and 3 with none. 1 inspection was prompted by a complaint.
Violations (45)
22VAC40-73-150-B: Facility failed to employ or appoint a qualified acting administrator immediately after previous administrator left.
22VAC40-73-190-C: Staff person in charge did not receive written documentation of duties and responsibilities prior to assignment.
22VAC40-73-320-A: Physical exam and TB assessment not completed within 30 days prior to admission for resident #4.
22VAC40-73-450-C: Individualized service plan failed to include identified needs and DNR status for residents #2 and #3.
22VAC40-73-640-A: Medication management plan failed to prevent use of contaminated medications; medication dropped and administered.
22VAC40-73-310-D: Facility failed to provide written assurance of appropriate license to resident or legal representative at admission.
22VAC40-73-260-A: Direct care staff member lacked current first aid certification in staff record.
22VAC40-73-350-B: Failed to ascertain and document sex offender status prior to admission for resident #6.
22VAC40-73-550-G: Failed to annually review rights and responsibilities with residents #3, #4, and #5.
22VAC40-73-490-A: Failed to provide health care oversight at least every six months for all assisted living residents.
22VAC40-73-200-D: Staff record missing certificate or documentation of meeting subsection C requirements for staff #3.
22VAC40-73-410-A: Failed to provide orientation including emergency procedures and call system to residents #7 and #5.
22VAC40-73-1100-A: Failed to obtain written approval for placement in special care unit for residents #6 and #7.
22VAC40-73-320-A: Physical exam did not include statement about prohibited conditions for residents #1, #2, #4, #5, #6, #7.
22VAC40-73-680-C: Medications administered outside one hour before or after scheduled time for resident #5.
22VAC40-73-260-A: Direct care staff member lacked current first aid certification in staff record.
22VAC40-73-110-1: Staff failed to be considerate and respectful of rights and dignity of resident #1; injuries and unreported incident.
22VAC40-73-450-D: Failed to coordinate hospice care plan with licensed hospice organization for resident #8.
22VAC40-73-1110-A: Failed to document determination and justification for placement in special care unit for residents #1, #5, #8.
22VAC40-73-290-B: Failed to post name of current on-site person in charge conspicuously; posted staff #5 not on-site.
22VAC40-73-610-B: Menus for current week not dated or posted conspicuously to residents.
22VAC40-73-580-A: Failed to comply with Virginia Department of Health inspection regulations; last health inspection dated 03/24/2022.
22VAC40-73-680-C: Medications administered outside one hour before or after scheduled time for resident #5.
22VAC40-73-260-A: Direct care staff member lacked current first aid certification in staff record.
22VAC40-73-490-A: Failed to retain licensed health care professional with required experience to provide on-site oversight.
22VAC40-73-450-E: Individualized service plan not signed and dated by licensee or resident for residents #4 and #6.
22VAC40-73-680-D: Failed to administer medications according to physician's instructions; missed doses for residents #3 and #4.
22VAC40-73-650-B: Prescriber's orders lacked diagnosis or specific indications for multiple medications for resident #1.
22VAC40-73-650-C: Physician's oral orders not reviewed and signed within 14 days for residents #1 and #4.
22VAC40-73-650-F: Failed to obtain new medication orders prior to or at time of return from hospital for residents #2 and #3.
22VAC40-73-310-D: Facility failed to provide written assurance of appropriate license to resident or legal representative at admission.
22VAC40-73-260-A: Direct care staff member lacked current first aid certification in staff record.
22VAC40-73-350-B: Failed to ascertain and document sex offender status prior to admission for resident #6.
22VAC40-73-550-G: Failed to annually review rights and responsibilities with residents #3, #4, and #5.
22VAC40-73-490-A: Failed to provide health care oversight at least every six months for all assisted living residents.
22VAC40-73-200-D: Staff record missing certificate or documentation of meeting subsection C requirements for staff #3.
22VAC40-73-430-H-1: Failed to provide dated discharge statement signed by licensee for residents #1 and #2.
22VAC40-73-990-C: Failed to document staff participation in emergency practice exercises at least every six months.
22VAC40-73-430-H-1: Failed to provide dated discharge statement signed by licensee for residents #1 and #2.
22VAC40-73-980-H: Failed to maintain 96-hour supply of emergency food and water with at least 48 hours on site.
22VAC40-73-970-A: Fire drills not conducted monthly with alternating shift times as required.
22VAC40-73-450-C: Individualized service plan failed to include description of identified needs based on UAI.
22VAC40-73-260-C: Listing of staff with current first aid or CPR certification posted but not current.
22VAC40-73-440-D: Uniform assessment instrument not completed as required; missing signatures and classifications.
22VAC40-73-260-A: Direct care staff members lacked current first aid certification or had uncertified certifications.
Report Facts
Violations cited: 40
Distinct standards: 32
Inspections on page: 11
Inspections with violations: 8
Complaint visits: 1
Employees mentioned
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