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. 6, 2021

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 initiated on 10/06/2021 by the licensing inspector and concluded on 10 22/2021 with the exit interview with the facility Administrator. The facility?s Divisional Director Operations was contacted by telephone and email to initiate the inspection. The Divisional Director Operations reported that the current census was 49. The inspector emailed the Divisional Director Operations a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 3 resident records, 3 staff records, the facility?s medication administration records, staff training/in-service, Uniform Assessment Instrument (UAI), ISPs, and facility nurses notes to ensure that documentation was complete. Information gathered during the inspection determined noncompliance with applicable standards or law, and violations were documented on the violation notice issued to the facility. If you have any questions I can be reached at (804z0 840-0253 or angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1140-D
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that the cognitive impairment training for staff was conducted by a licensed health care professional practicing within the scope of his profession who has at least 12 hours of training in the care of individuals with cognitive impairments due to dementia; or a person who has been approved by the department to develop or provide the training. Evidence: Facility staff #3 Documented date of hire 09/15/2021 Upon request to review the training record for facility staff #3 the facility submitted a document that is signed by facility staff #1 and notes in part ?(facility staff #3 identified) has received 8 hours of dementia training on 9/17/21; 9/22/21; 9/24/21; 9/25/21; 9/26/21?. Facility staff #1 reported to the department that she was not a licensed health care provider. Upon further review the department has no documentation that approval was given for staff #1 to develop or provide the cognitive impairment training for facility staff.
Plan of Correction:	FACILITY'S RESPONSE: "Facility Staff # 3 completed all required in servicing during onboarding and hiring process. This process is electronic, and documents were sent for review during the inspection. An additional document was sent by staff # 1 that was a review on the required in servicing. This document is not accurate and not standard practice, staff #1 did not provide this training."
Standard #:	22VAC40-73-1180-A
Description:	Based on observation and interviews conducted the facility failed to ensure that special environmental precautions are taken by the facility to eliminate hazards to the safety and well-being of residents. Evidence: Resident #4 While on site at the facility on 10/22/2021 during the breakfast time meal the inspector observed resident #4 aggressively and continuously enter the kitchen area of the safe and secure environment where the hot food warmer station was set up. The inspector visibly saw steam coming from the food warmer unit. Facility staff acknowledged that the food warmer unit was hot and hazardous to all residents. During interviews facility staff stated that the behavior of the resident on this day is a constant occurrence. Facility staff further stated that they were not allowed to put barriers up as management has informed the staff that this is the resident?s home and they should be allowed to go anywhere they wanted to. The facility did not put barriers in place that would prevent cognitively impaired residents from entering areas on the safe and secure environment that presents the potential for severe risk of harm.
Plan of Correction:	FACILITY'S RESPONSE: "Resident #4 has a diagnosis of dementia. Staff will be reeducated in daily meetings on resident safety in the kitchen area until modifications are completed. Continued education to be completed on 11/29/2022 on Dementia and problem behaviors by Home Care Hospice. The Steam table area is being evaluated for a protective barrier and modifications will be made to the area to protect residents from being able to have access to the area. Facility is awaiting an estimate and installation date. All other equipment in the Memory Care Serving area has safety measures in place."
Standard #:	22VAC40-73-40-A
Description:	Based on the review of facility records the Licensee failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department; with relevant federal, state, and local laws; with other relevant regulations; and with the facility's own policies and procedures. Evidence: Resident #3 The facility?s PP - 61050 - Medication Management (VA) policy that the facility submitted for the inspector?s review via email on 10/13/2021 notes the following on page 1/16 : d)-If the Resident uses the Branch's preferred pharmacy, the Branch will request a refill of all prescription medications managed by the Branch when the quantity of medications on hand is enough for seven days. e)-If a Resident does not use the Branch's preferred pharmacy, the Branch will notify the Resident and the Resident's personal representative when the quantity of medications on hand is enough for ten days. The resident?s MAR charting for August 2021 noted that for three days 08/16, 17, 18/2021 the medication Metoprolol was not administered documenting; ?no supply, notified RNC.? For six days beginning 10/08, 09, 10, 11, 12, 13/2021 facility staff documented that the 25 mg tablet of the prescribed medication Metoprolol to be administered every evening was not administered to the resident documenting: no supply, notified RNC. The facility is not following their own policy.
Plan of Correction:	FACILITY'S RESPONSE: "RNC will print the med exceptions daily to ensure medications are available and occurring as prescribed. 2. RMA?s will be re-educated on reordering of medication 3. A 4-week audit will be completed by the Director and the RNC to ensure the medication reordering process is occurring within facility policy and procedures 4. RNC will print POS for Physician signature monthly and fax to the resident pharmacy to ensure accuracy of cycle medications."
Standard #:	22VAC40-73-40-B-12
Description:	Based on the review of facility records the facility failed to ensure that at all times the department's representative is afforded reasonable opportunity to inspect all of the facility's buildings, books, and records and to interview agents, employees, residents, and any person under its custody, control, direction, or supervision as specified in ? 63.2-1706 of the Code of Virginia. Evidence: Upon request the facility did not submit for the inspector?s review documentation of the facility?s Disclosure Statement document.
Plan of Correction:	FACILITY'S RESPONSE: "The Disclosure Statement is in use on all admissions. Facility failed to submit with original documentation submission. 2. It is also available in the facility for viewing for anyone interested."
Standard #:	22VAC40-73-40-B-6
Description:	Based on correspondence with the facility, the review of facility records and interviews conducted the Licensee failed exercise general supervision over the affairs of the licensed facility and establish policies and procedures concerning its operation in conformance with applicable law, this chapter, and the welfare of the residents. Evidence: ? On 08/04/2021 via an email the previous Administrator reported to the Division of Licensing Programs that her last day of employment at the facility would be 09/04/2021. ? On 09/07/2021 facility staff #1 notified the department via an email that she was? the new divisional over Virginia Area.? Facility staff #1 stated during a telephone interview 09/23/2021 that she does not hold licensure or certification in the state of Virginia that would allow her to be responsible for the day to day operation and management of the facility. ? 10/11/2021: The department was notified via an email with an attachment from facility staff #1 reporting ?Our new Director (facility staff #5 identified) starts onsite today. For thirty-seven (37) days beginning 09/05/2021 until 10/11/2021 the Licensee did not ensure that facility staff #1 or any other individual was identified or onsite that met the qualifications as the individual that would be responsible for the day to day operation and management of the facility as required in the current Regulations for Licensed Assisted Living Facilities. Additionally: ? Unqualified and unauthorized staff are providing cognitive impairment training. ? The current facility Administrator as of 10/11/2021 is also the documented Administrator of record for the licensed Bickford assisted living facility in Fredericksburg, Virginia. The facility Administrator cannot serve as the Administrator for two facilities. ? PRN medications are being administered by registered medication aides (RMA) without required authorization/documentation. ? Resident Individualized Care Plans (ISP) are not developed and updated based on assessed needs. ? The Licensee did not ensure that the facility maintained consistent compliance as required based on current regulations for Licensed Assisted Living Facilities.
Plan of Correction:	FACILITY'S RESPONSE: "On 8/4/2021 the previous facility administrator reported last day of employment with Bickford of Chesterfield as 9/4/2021. On 9/7/2021 DSS was notified of a new regional for the Division and recruitment efforts to fill the vacant administrator role at the Chesterfield branch was in the process. The Regional Operations Director was qualified to operate an Assisted Living in the state of Illinois but not the State of Virginia. 1.The Chesterfield Administrator position was filled on October 11th with a licensed Administrator for the state of Virginia. The Board of Long-Term Care was notified on 10-11-2021 and the Department of Social Services on 10-7-2021. The onsite RN Coordinator was in the branch during this period of recruitment for an Administrator and would be the DFG in charge of the general supervision over the affairs of the licensed facility as stated by facility policy to remain in compliance with applicable laws and the welfare of the residents. Facility will follow regulations and guidelines set forth on having a qualified administrator appointed. The RN Coordinator, Assistant Care Coordinator have a signed Chore CQ (Job Description) , Organizational chart RNC Training Review and regulation book ensuring compliance with state regulations duties and responsibilities when the Administrator is not in the facility."
Standard #:	22VAC40-73-120-B
Description:	Based on the review of facility records the facility failed to ensure that orientation and training required about compliance with regulations for assisted living facilities as it relates to their duties and responsibilities occurred within the first seven working days of employment. Evidence: Facility staff #2 Facility records submitted for the inspector?s review identifies the staff as the Registered Nurse Coordinator and notes the date of hire as 07/26/2021. Upon request the facility did not submit for the inspector?s review documentation that facility staff #2 was provided initial orientation and training regarding compliance with regulations for assisted living facilities as it relates to their duties and responsibilities occurred within the first seven working days of employment.
Plan of Correction:	FACILITY'S RESPONSE: "The Registered Nurse Coordinator has a Chore CQ (Job Description) signed at dated 7/26/2021 and an organizational chart received within 7 working days of employment. The RNC Training Review was completed 7/29/2021 and was not submitted with the inspection documents was submitted with the POC."
Standard #:	22VAC40-73-150-B-2
Description:	Based on the review of emails received at the department and interviews conducted the facility failed to immediately notify the Virginia Board of Long-Term Care Administrators and the department's regional licensing office that the licensed administrator resigned, 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: On 08/04/2021 via an email the previous Administrator reported to the Division of Licensing Programs that her last day of employment at the facility would be 09/04/2021. The facility did not contact the department until 09/07/2021 via an email when the licensing inspector directed facility staff #1(not qualified) to Virginia Long Term Care Board to make a report of who the licensed assisted living facility Administrator would be and to submit documentation of the qualifications of the individual to the board as well. In response to the inspector?s email inquiry whether the Board Long Term Care Administrators (VLTCA) were notified that the facility is operating without a licensed assisted living facility administrator and if the board was notified prior to the contact made with facility staff #1 on 09/24/2021; On 09/28/2021 via email a representative with the VLTCA responded stating ?We were not notified. (Facility staff # identified) contacted the Board inquiring about licensure on 09/24/2021.?
Plan of Correction:	FACILITY'S RESPONSE: " (1).The Virginia Board of Long-Term Care was notified of the facility Administrator leaving the Spotsylvania Branch and beginning oversight at the Chesterfield Branch on Oct. 11th. 2. Bickford of Chesterfield failed to report the previous Administrators resigning on 9/4/2021 to the Board of Long-Term Care and the Department of Social Services. 3. The Long-Term Care Board and the Department of Social Services notified on 10-11-2021 of the new Administrator arrival to Bickford of Chesterfield. 4. Divisional Director of Operations will ensure the Virginia Board of Long-Term Care is notified immediately with changes in Administration. 5. Notify the Departments Regional Licensing office in writing immediately with a change in Facility Administration"
Standard #:	22VAC40-73-170-B
Description:	Based on the review of facility records, interviews conducted and department records the facility failed to ensure that for a facility licensed for both residential and assisted living care, the administrator, who is licensed as an assisted living facility administrator or nursing home administrator by the Virginia Board of Long-Term Care Administrators, may be responsible for the day-to-day administration and management of multiple facilities under the following conditions: Evidence: The current licensing inspector for the Bickford Spotsylvania facility confirmed on 10/22/2021 that facility staff #5 is the Administrator of record for the Bickford of Spotsylvania. 2-Combined total licensed capacity of the facilities served by the administrator shall be 40 or fewer residents; Documentation on file at the department notes that the combined total licensed capacity for both licensed assisted living facilities is 148. 4- Each of the facilities served shall be within a 30-minute average one- way travel time of the other facilities. Google Maps note that the drive time from Chesterfield Virginia to Fredericksburg Virginia is 1 hour and 14 minutes.
Plan of Correction:	FACILITY'S RESPONSE: "The Spotsylvania DSS Licensing inspector was notified of the change in Administrator for the Bickford of Spotsylvania on 10/7/2021, as well as the Board of Long-Term Care on 10/11/2021."
Standard #:	22VAC40-73-440-H
Description:	Based on the review of facility records the facility failed to ensure that reassessments due to a significant change in the resident's condition, using the UAI, was utilized to determine whether a resident's needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: Resident #2-Documented date of admission 07/22/2021 The resident?s most recent 10/13/2021 UAI that was submitted for the inspectors? review notes that facility staff assessed the resident as being independent with Eating/Feeding. Facility staff documented on the facility?s progress notes document on 10/05/2021 ?continues to need assistance with ADLs?. While on site at the facility on 10/22/2021 the inspector observed the resident being fed breakfast by a care taker. The resident has been inappropriately reassessed. The facility Administrator (staff #5) and facility staff #4 signed the 10/13/2021 UAI.
Plan of Correction:	FACILITY'S RESPONSE: "Resident #2 admitted 7-22-2021. Resident was admitted for Hospice Services on 9/24/2021 and discontinued on 10/14/21 and another Hospice service assigned on 10/14/2021 at the POA request to utilize another Hospice agency. Resident #2 had a UAI/ISP completed on 10/13/2021 and 10/14/2021 due to changing medical needs. Resident #2 ISP updated on 10/14/21 to reflect the need for supervision during meals, cueing as needed and hand over hand assistance as needed, this can initiate resident to independently feed himself. If unsuccessful, staff will assist in feeding resident. 1.A 100% ISP/UAI audit will be done by the Director and RN Coordinator and ACC for the next 8 weeks to evaluate and ensure accuracy, compliance and appropriate level of care placement."
Standard #:	22VAC40-73-450-F
Description:	Based on the review of facility records the facility failed to ensure that the Individualized service plans were reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: Resident #2 Documented date of admission 07/22/2021 09/24/2021: Facility staff documented on the facility?s progress notes document that resident # 2 was admitted to (Hospice agency identified) hospice. 10/05/2021: Facility staff documented on the facility?s progress notes document that resident # 2 continues to need assistance with ADLs, resident transfers with Hoyer lift, two person assist. 10/12/2021: In response to the inspectors? request for facility data regarding residents that receive hospice services; facility staff identified resident #2. The resident?s most recent 08/24/2021 ISP that was submitted for the inspector?s review was not updated to identify that the resident is now a two person assist and in need of a Hoyer lift for transfers nor did the ISP identify the responsibilities of the hospice agency and facility staff for ensuring how the assessed service needs of the resident would be carried out by each entity.
Plan of Correction:	FACILITY'S RESPONSE: "Resident #2 received order to utilize Hoyer lift for ease of transfers on 9/17/2021. ISP and UAI were updated on 10/13/2021 and 10/14/2021 to reflect the changes in the resident with the coordination of assigned Hospice agency. 1.100% ISP/UAI Audit review to be completed to ensure resident needs are being met and meeting regulation guidelines and reviewed/signed and put in resident chart."
Standard #:	22VAC40-73-650-E
Description:	Based on the review of facility records the facility failed to ensure that resident?s record contained the physician's or other prescriber's signed written order or a dated notation of the physician's or other prescriber's oral order. Orders shall be organized chronologically in the resident's record. Evidence: Resident #2 10/05/2021: Facility staff documented on the facility?s progress notes document that resident # 2 continues to need assistance with ADLs, resident transfers with Hoyer lift, two person assist. 10/12/2021: Via an email the inspector requested all current physician?s orders (i.e. medications, treatments, home health, etc.) In response the facility submitted physician?s orders dated October 7, 2021 that does not identify that a Hoyer lift is prescribed. Upon request for the inspector?s review the facility did not submit current physician?s orders for resident #2.
Plan of Correction:	FACILITY'S RESPONSE: "Resident #2 received order to utilize Hoyer lift for ease of transfers on 9/17/2021. Resident ISP was updated on 10/13/21 and 10/14/2021 to reflect the changing needs of resident. The most current ISP's were not submitted at time of inspection for review. 100% UAI/ISP chart during the next 8 weeks Audit will include ensuring the most current ISP is being utilized in resident chart."
Standard #:	22VAC40-73-680-I
Description:	Based on the review of facility records the facility failed to ensure that facility Medication Administration Records (MARs) included any medication errors or omissions. Evidence: Resident #2 The facility?s MARs charting for August and September 2021 revealed seventeen (17) different times that the resident MARs did not identify any reason for the medications not being administered or whether the medications were actually administered.
Plan of Correction:	FACILITY'S RESPONSE: "Resident # 2 MAR for August 28 showed a computer failure and written MARS were utilized and sent to Licensing agent after the inspection was completed. RNC will print Emar report daily to identify missing documentation and address incidents the day of occurrence. Staff education on medication documentation will be done by a licensed and qualified person is scheduled for 11/24/21"
Standard #:	22VAC40-73-680-K
Description:	Based on the review of facility records the facility failed to ensure that the use of PRN medications is prohibited, unless one or more of the allowed conditions exist. Evidence: Resident #3 Facility registered medication aides (RMA) documented the following: 09/06 at 10:34p.m two 500mg tablets of the medication Acetamin was administered to the resident 09/18/2021 at 11:19a.m one tablet of the medication Acetamin was administered to the resident Facility registered medication aides (RMA) documented that PRN-as needed medication was administered to resident #3 without authorization from the prescribing physician.
Plan of Correction:	FACILITY'S RESPONSE: "9/6 resident #3 was administered 2- 500mg tablets of the medication Acetamin at 10:34p.m. For pain 9/18 resident #3 Acetamin was administered to the resident for pain two times as prescribed on that date. resident #3 has a Physicians order to Take 1-2 Tabs (500-1000mg) by mouth every eight hours as needed for pain."