VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bickford of Chesterfield
11200 W. Huguenot Road
Midlothian, VA 23113
(540) 898-1205

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Oct. 16, 2019

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

An unannounced renewal inspection was conducted at the facility during the approximate time of 11:30am to 4:30pm on October 16, 2019. The entrance interview was conducted with the facility Administrator. The facility offered 52 residents in care. Based on the census offered eight residents, four staff and other facility records were reviewed for compliance. The facility reported new resident admissions and new staff hires since the last on-site inspection. Based on observation, the review of facility records and interviews conducted, noncompliance was revealed and is contained within this report. A noon time medication pass and lunch time meal were observed. Observation of the physical plant revealed no concerns. The inspectors also observed the residents during an afternoon activity. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the Inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 1) steps to correct the non-compliance 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). If you have any questions please feel free to contact me at 804-662-9774 or angela.r.reaves@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-320-B
Description:	Based on the review of facility records with the facility Administrator and other administrative staff on 10/16/2019 the facility failed to ensure that an annual risk assessment for tuberculosis was completed on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Resident #s 1-Documented date of admission 01/17/2017-The facility did not submit upon request documentation that an annual tuberculosis risk assessment was conducted on the resident. Resident # 5-Documented date of admission 01/24/2017- The tuberculosis report submitted for the inspector?s review is dated 06/05/2018 Resident # 8- Documented date of admission 01/16/2017- The facility did not submit upon request documentation that an annual tuberculosis risk assessment was conducted on the resident.
Plan of Correction:	FACILITY RESPONSE "The insufficiency will be corrected as follows: ? The identified residents? PCPs have been contacted and dates for their annual tuberculosis screening have been set up for 10/22/2019. The following measures will be taken to ensure the problem does not recur: ? Residents will have annual TB screening per policy and regulation ? Quarterly Health Care Oversight will be completed to audit TB screenings ? A TB binder will be created to update monthly residents who need the annual tb screening Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? Director and RNC"
Standard #:	22VAC40-73-620-A
Description:	Based on the review of facility records and interviews conducted with the facility Administrator and other facility administrative staff on 10/16/2019 the facility failed to ensure that the oversight of residents? special diets was conducted. Evidence: The facility?s dietician report dated 09/04/2019 that was submitted for the inspector?s review is not documented to identify that oversight of the residents diets were conducted.
Plan of Correction:	FACILITY RESPONSE "The insufficiency will be corrected as follows: ? The Director forwarded the most current Dietitian?s report to Bickford?s Vice President of Dining to review and discuss with the dietician what is required for oversight of special diets to make sure it is addressed in future visits on 10/18/19 The following measures will be taken to ensure the problem does not recur: ? Dietician will visit every six months with review to include special diets ? Dietician report will be reviewed with dietician onsite during visits Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? Director and RNC
Standard #:	22VAC40-73-720-E
Description:	Based on the review of facility records with the facility Administrator and other administrative staff on 10/16/2019 the facility failed to ensure that the residents do not resuscitate order was included in the resident's individualized service plan. Evidence: Resident # 2- ISP dated 08/29/2019 Resident # 3-Comprehensive ISP dated 10/10/2019 Facility records submitted for the inspector?s review revealed that the resident?s signed Do Not Resuscitate order was not included on their ISP.
Plan of Correction:	FACILITY RESPONSE "The insufficiency will be corrected as follows: ? Identified residents # 2 and # 3?s Individualized Service Plans have been updated to reflect their do not resuscitate order 10/18/19. ? 100% of resident ISPs will be audited for compliance by 11/1/19 The following measures will be taken to ensure the problem does not recur: ? ISP will reflect code status in safety section of ISP ? Director will review ISP on completion ? All new Residents ISPs and a random sampling of 5 existing Residents will be audited each month for compliance for the next 3 months Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? Director and RNC"