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: Sept. 20, 2022 and Oct. 12, 2022

Complaint Related: No

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/20/2022-10:54 a.m. 10/12/2022: 12:56a.m.-3:11p.m 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: 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: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Staff?s interaction with the residents Additional Comments/Discussion: 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 Angela Rodgers-Reaves, Licensing Inspector at (804)840-0253 or by email at angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-E
Description:	Based on the review of facility records and interviews conducted with facility staff the facility failed to ensure that individualized service plan (ISP) are signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. Evidence: Resident #1: Documented date of admission 09/17/2022. ISP dated 09/16/2022. Resident #3: Documented date of admission 03/16/2020 06/30/2022 Resident #5: Documented date of admission ISP 08/25/2022 Resident #6: Documented date of admission. ISP dated 09/08/2022 The residents most resident ISPs that were submitted for the inspector?s review revealed that the signature pages for the residents were not signed by a facility representative, the resident or a legal representative. The signature sections of the ISPs is blank.
Plan of Correction:	0FACILITY'S RESPONSE: "On or within 7 days of admission the preliminary care plan will be developed by the Nurse Manager to address the basic needs of the resident to protect safety, health and well-being. This document will be signed by the licensee, administrator, or his designee and the resident or legal representative. The comprehensive ISP shall be completed within 30 days after admission. The ISP will be signed and dated by the licensee. Administrator, or designee and by the resident or designee. 10//31/22 for new admissions 5/1/2022 All charts will be reviewed, and signatures completed for existing ISPs that are missing signatures"
Standard #:	22VAC40-73-460-B
Description:	Personal care services and general supervision and care. (B1) Based on the review of facility records the facility failed to ensure personalization of care and services tailored to the resident's circumstances and preferences. Evidence: Resident #3: Documented date of admission 03/16/2022 The facility?s 05/24/2022 dietician review report referring to the facility and the resident?s dietary intake noted ?They note a decrease of intake.? The report further notes that the resident said that he wanted to lose weight. Upon request the facility did not submit documentation for the inspector?s review that identified a plan of care based on the resident?s preferences or that was guided by the resident?s physician.
Plan of Correction:	FACILITY'S RESPONSE "Care provision and service delivery will be resident centered to the maximum extent possible and will include personalization of care and services tailored to the residents? circumstances and preferences. Dietician?s quarterly reports will be documented by Nurse Manager in resident chart, interventions based on residents preferences or physician guided and documented in resident care plan."
Standard #:	22VAC40-73-580-F
Description:	Based on the review of facility records and interviews conducted the facility failed to implement interventions as soon as a nutritional problem is suspected. Evidence: Resident #6: Documented date of admission 09/21/2017 The facility?s 05/24/2022 dietician review report noted that the resident had lost 6 pound since March 2022; 161lbs to 156lbs. The facility?s Weights and /vitals Record document that was submitted for the inspector?s review noted the following weights: June 142 lbs. August 135 lbs. September 134.6 lbs. October 133.0 lbs. Upon request the facility did not submit documentation for the inspector?s review that identified that interventions had been implemented to address the resident?s continuous weight loss.
Plan of Correction:	FACILITY'S RESPONSE "Dieticians? quarterly reports will be documented in resident chart, interventions based on residents preferences or physician guided and documented in resident care plan. Weight loss trends are reviewed monthly and documentation will be completed by the Nurse Manager and care plan interventions completed once the review is complete."
Standard #:	22VAC40-73-720-A
Description:	Based on the review of facility records the facility failed to ensure that written Do Not Resuscitate Orders is included in the individualized service plan. Evidence: Resident #1 Documented date of admission 09/17/2022 The review of the resident?s most recent 09/16/2022 ISP was not documented to note the residents DNR orders.
Plan of Correction:	FACILITY'S RESPONSE "Audit will be completed by the Nurse Manager of all resident ISPs to ensure all code status is complete and documented in ISP."