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. 12, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS

Comments:

A non-mandated complaint investigation was initiated on 10/12/2021 and concluded on 11/19/2021. A complaint was received by the department regarding allegations in the areas of resident care and related services, personnel and medication administration. The facility Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the facility Administrator a list of facility documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law.

Violations:

Standard #:	22VAC40-73-100-A
Complaint related:	No
Description:	Based on observation the assisted living facility failed to implement an infection control program addressing the surveillance, prevention, and control of disease and infection that is consistent with the federal Centers for Disease Control and Prevention (CDC) guidelines and the federal Occupational Safety and Health Administration (OSHA) blood borne pathogens regulations. Evidence: While on site on 10/22/2021 the inspector observed various residents inside the facility not wearing a face covering. Upon further inquiry a resident stated that no one told them that they had to wear a mask while inside the building. The inspector also observed multiple facility staff and a contract aide enter and exit the facility through a side door of the facility. The facility Administrator was shown the area where individuals were entering/exiting the facility that did not have a COVID-19 screening station.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-40-A
Complaint related:	No
Description:	Based on the review of facility records and interview conducted the facility 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 #2 The facility?s PP-20700 ? Communication Policy (VA) notes in part on page one #2 ?At the end of each shift, Bickford Family Members shall document pertinent resident information, from their shift, in the Communication Book.? While on site in the facility?s safe and secure environment on 10/22/2021 the inspector observed resident #2 being continuously physically and verbally aggressive towards facility staff #2. The facility?s Communication Log charting for 10/22/2021 that the facility submitted for the inspector?s review via email on 11/12/2021 is not documented to note the observed aggressive behaviors of resident #2.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-40-B-12
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted with the facility Administrator 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: The inspector sent emails to the facility Administrator requesting facility documentation and asking that the facility Administrator respond whether the facility maintained such documentation or not; the facility Administrator did not respond to the inspector?s request for documentation or the inquiry for the following facility documentation: Resident discharge documentation Facility Communication Logs Facility End of shift reports The facility?s Medication Administration exception report for 10/22/2021.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-250-C
Complaint related:	No
Description:	Based on the review of facility records submitted and interviews conducted with the facility Administrator and facility staff the facility failed to ensure that an original criminal record report and a sworn disclosure statement was obtained for all staff. Evidence: Staff #1- Seeking clarification whether the facility had obtained and or reviewed the criminal record check for facility staff #1 the facility Administrator responded via email on 11/15/2021 ?Neither (facility staff #3 identified) or myself had reviewed the criminal records report for an individual agency staff person. We have a contract with (facility staff #1 identified) agency, and they ensure all regulations and requirements are met for their staff being utilized at our branch as per our contract.? As defined in 22VAC40-90-10. REGULATION FOR BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES AND ADULT DAY CARE CENTERS; ?Employee also includes those individuals hired through a contract to provide services for the facility.? The facility did not submit upon request for the inspector?s review documentation that a Virginia State Police criminal record report was obtained for facility staff #1.
Plan of Correction:	FACILITY RESPONSE" "1. All Bickford employees meet VAC 40-90- 40 administrative code. 2. If supplemental agency staffing is being utilized the Director will ensure VAC 40- 90- 40 is being followed per regulation."
Standard #:	22VAC40-73-430-H-1
Complaint related:	No
Description:	Based on the review of facility records the facility failed to ensure that at the time of discharge, the assisted living facility shall provide to the resident and, as appropriate, his legal representative and designated contact person a dated statement signed by the licensee or administrator that contained all of the required elements. Evidence: Resident #5 The facility?s Progress Notes document that was submitted for the inspector?s review charting for 09/01/2021 in part notes ?Received pt without pulse or respirations Pronounced death.? The facility did not submit upon request facility documentation that a dated and signed discharge statement was provided to the resident and or legal representative.
Plan of Correction:	FACILITY RESPONSE: "1. VDSS Discharge Statement form is utilized according to 22VAC40-73-430 as of 11/7/2021 upon the new Directors employment. 2. The exception however, the document was not being used upon death of a resident. It is being used for all discharges as of 12/1/2021."