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. 10, 2023

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: 10/06/2023 approximate time 11:30-2:30p.m. On 10/10/2023 approximate tie 9:16a.m-11:41a.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: 51 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: 5 Number of interviews conducted with staff: 5 Observations by licensing inspector: 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 Violation Notice Issued: Yes

Violations:

Standard #:	22VAC40-73-720-A
Description:	Based on the review of facility records and staff interviews the facility failed to ensure that Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest is included in the individualized service plan (ISP). Evidence: Resident #1 The resident?s 10/02/2023 ISP that was submitted for the inspector?s review on is not documented to note that the resident has a signed DNR on file at the facility or the responsibility of facility staff to fulfil the DNR order.
Plan of Correction:	Nurse Manager and Director will complete an ISP review to ensure all DNR orders are included in each resident ISP.
Standard #:	22VAC40-73-870-B
Description:	Based on observation the facility failed to ensure that the building is free from foul, stale and musty odors. Evidence: Upon entry to the safe and secure environment on 10/06/2023 the inspector encountered a foul odor in the common/dinning area of the unit.
Plan of Correction:	Foul odor had dissipated on return to the unit and was a temporary odor of urine. Carpet was cleaned on 10/14/2023 to ensure a more broad problem had not occurred. Carpets are cleaned on a monthly basis and as needed. Maintenance is responsible for maintaining the scheduled cleaninq process.