VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bickford of Suffolk
6860 Harbour View Boulevard
Suffolk, VA 23435
(757) 215-0058

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: April 10, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 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 22VAC40-90 Background Checks for Assisted Living Facilities

Technical Assistance:

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Comments:

An unannounced monitoring inspection was conducted on this date from(10:50a.m until 6:07p.m ) to follow-up on the previous violations. There were 60 residents in care. Three new resident records were checked . All new hire background check were reviewed. First aid and CPR certifications were checked . The lunch meal of Burgundy beef, or baked ham ,mixed veggies , collard greens roll, and fruit pie was observed. The cook was advised to name the fruits or desserts to be served . While on the secure unit with the cook ,she was advised to keep the snacks on the secured unit well stocked as staff on the unit can not readily leave the unit . Some ice cream sandwiches and cookies were observed on the secure unit. The assisted living section snacks included fruit water, assorted fresh fruits, and assorted fresh baked. goods. Encouraged staff not to use the residents' private supply of medications and the bubble packs of medications at the same time. Per the nurse supervisor medication times are now staggered. Reviewed the requirements for sitters/companions Encouraged staff to take the updated ISP course. The activity observed was coffee club and later black jack, bible study,and happy were planned. Water temperature checked and ranged between 105.3 up to 112.8. The facility now has a portable rug cleaner . A resident will be having Plexiglas install on his wall to enhance cleaning . Sex offender checks were completed as required on new admission files checked. Please complete the ?plan of correction? for each violation cited on the violation notice and return it to me within 10 calendar days from today on 5-2-19 You will need to specify how the violation will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must include: 1. steps to correct the noncompliance 2. measures to prevent reoccurrences 3. Person(s) responsible for implementing and monitoring each step of the corrective measures and / or the preventative measures

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based on record review and interview the facility failed to ensure each direct care staff member had a current certification in first aid within 60 days of employment Evidence 1. While reviewing staff certifications in first aid with staff # 4 and #5 , the inspector found two part time as needed staff did not have a certification in first aid within 60 days of their hire date . 2. Neither staff # 7 hired 1-10-19 or staff #8 hired 1-7 19 had documentation of a current certification in first aid on file . 3. Staff #4 acknowledged the staff did not have first aid certifications on file.
Plan of Correction:	Staff # 4 and #5 were informed that First Aid certification must be obtained to remain in active status. Compliance initiative: Director will audit personnel files to insure current certifications are in place
Standard #:	22VAC40-73-390-C
Description:	Based on record review and interview the facility failed to ensure a resident's original agreement/acknowledgment was updated when there was a change in information referenced or identified in the agreement/acknowledgment dated and signed by the licensee or administrator and the resident or his legal representative. Evidence 1. During a review of resident #7' record with staff # 4 and #5 , the inspector found no updated agreement was signed and dated by the administrator or licensee and the resident or his legal representative . 2. The inspector noted that the resident was admitted to the facility 8-29-18. On 2-15 19 the resident moved to the secured unit following the doctor's assessment , the family's approval and the administrator's justification. 3. The facility did not have an updated signed and dated agreement on file. 4. The staff acknowledged the agreement had not been updated.
Plan of Correction:	New lease provided to POA since the resident #7 transferred from AL to Mary B?s Compliance initiative: Director and CRD to review together new admission and transfer documentation.
Standard #:	22VAC40-73-440-D
Description:	Based on record review and interview the facility failed to ensure two of the three private pay uniform assessment instruments in the record sample , were completed as required. Evidence 1. During a review of resident records with staff #2,# 4, and #5 , the inspector found resident # 6 ,admitted 2-25-19, had no dependencies in activities of daily living but was assessed at the assisted living level(requiring assistance with two or more activities of daily living ). 2. Also the inspector found resident # 8 admitted 2-1-19, had no dependencies in activities of daily living but was assessed at the assisted living level (requiring assistance with two or more activities of daily living ) . 3. The staff confirmed the residents had not been assessed correctly.
Plan of Correction:	Resident #6 and resident #8?s UAI were corrected to `Residential? status reflecting their current status. UAI documentation was reviewed regarding `residential status vs. AL status as it relates to dependent ADLs. Director completed UAI online training
Standard #:	22VAC40-73-450-F
Description:	Based on record review and interview the facility failed to ensure two of three of the Individualized service plans reviewed had been updated as the condition of the resident changed. The update shall be performed by a qualified staff person and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons. Evidence 1. During a review of the resident records with staff #2, # 4, and #5 ,the inspector found the following : a. resident #7's ISP dated 2-18-19 had not been updated to include the PT and OT started 9-3-18 and still in progress as of the day of the inspection, interventions for the repeat falls mentioned in a doctor's note dated 12-10-18, or the POA who handles the residents's funds b. resident # 8's ISP dated 3-3-19 had not been updated to include the POA or the mental health follow-up services advised by the doctor on the admission exam dated 1-31-19. 2, The staff acknowledged the ISPs did not include all the required information.
Plan of Correction:	Nurse Coordinator and Director have made the following corrections - Resident #7?s ISP was updated with the addition of PT and OT that began on 9-3-18. Resident #8?s ISP was reviewed and updated with POA and mental health follow up per H&P. Nurse Coordinators (second nurse coordinator began May 1) and Director will audit ISPs and make indicated updates / changes. ISPs will include PT, OT, ST and all other medical services currently involved in the resident?s care. ISPs will reflect any change in residents? health status, change in POA, addition of any devices such as glasses, grabber, hearing aids, per the regulation. Expected outcome of additional / supplemental medical services will be noted on ISP. Updates made to the ISP will include input from interdisciplinary team and POA / family.
Standard #:	22VAC40-73-640-A
Description:	Based on observation and interview the facility failed to implement a written plan for medication management. The facility's medication plan shall address procedures for administering medication and shall include: Methods to prevent the use of outdated, damaged, or contaminated medications; Evidence 1. While checking the medication cart with staff # 1 and #2 ,the inspector found the following expired medications in the medication cart on the secure unit: a. resident #3's Tylenol 500mg and Tylenol 325mg both expired 12-20-18 and Pyridum 100mg expired 2-10-19 b.resident #4's Lasix 20mg as needed for 7 days ordered 10-28-18 still in the drawer c. resident #5's Compazine 10mg expired 9-14-18 2. Staff # 1 and #2 acknowledged the medications were still in the medication cart.
Plan of Correction:	Nurse Coordinator and RMA removed expired Tylenol 500mg and Tylenol 325mg and Pyridum 100mg on medication cart for resident #3. Resident #4?s Lasix ordered for 7 days 10-28-18 was removed from drawer. Resident #5?s expired Compazine 10 mg was also removed. Intervention to comply with regulation: Nurse Coordinators to perform medication cart audits weekly. Night shift RMA in charge for AL and Mary B?s will perform weekly cart audits to remove expired medications.
Standard #:	22VAC40-73-660-A-6
Description:	Based on observation and interview the facility failed to ensure when required, medications were refrigerated. Evidence 1. During the medication cart check with staff #1 and #2 ,the inspector found resident #1's 3-20-19 supply of Lactinex Chew before meals twice daily (probiotic) in the medication cart. 2. The medication label indicated was to be refrigerated. 3. Staff 1 and #2 checked the label and confirmed the label indicated the medication should be refrigerated .
Plan of Correction:	Nurse Coordinator and RMA moved resident #1?s Lactinex Chew to refrigerator Compliance initiative: In-services for RMAs are scheduled twice monthly. The agenda includes med administration, medication storage and cart audits.
Standard #:	22VAC40-73-680-D
Description:	Based on observation , record review,and interview the facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence 1. While checking the medication cart with staff #1 and #2 , found a resident's Fosamax pill had not been given as instructed. The inspector observed there were 6 of the 12 pills remaining in resident # 2's, 1-16-19 supply of Fosamax, instructed to be given weekly on Fridays . Also the inspector observed the 3-12-19, supply of 12 pills had not been open. 2. Staff #1 and #2 confirmed the number of pills remaining in the drawer.
Plan of Correction:	Nurse Coordinator met with RMA and reviewed physician?s order for resident #2?s Fosamax Intervention to comply with regulation: Nursing specific in-services implemented to include review of medication administration - timeliness and technique outlined in the medication management plan. These in-services will be provided by Nurse Coordinators and Director.
Standard #:	22VAC40-73-680-G
Description:	Based on observation and interview the facility failed to ensure all over-the-counter medications in the original container were labeled with the resident's name, or in a pharmacy-issued container, until administered. Evidence 1. While checking the medication cart in the assisted living section with staff # 3, and #4 , the inspector observed the following residents' unlabeled over the counter medications in the medication cart a. resident 8's Aspirin 81 mg and Vitamin D3 b. resident 9's Vitamin D3 2. Staff #3 confirmed the over the counter medications were not labeled . The staff stated a section of the medication cart is identified for each resident's medication .
Plan of Correction:	Nurse Coordinator corrected Resident #8?s unlabeled Aspirin and Vit. D3. Also corrected Resident #9?s labeling of Vitamin D3 Initiative implemented to be in compliance with regulation: Nurse Coordinators will include in the med cart audits - noting over the counter meds, unlabeled meds, and clear delineation of med storage per resident on the cart and in the refrigerator. All meds, prescribed and over the counter will include the resident?s name or the pharmacy label ? on going basis. Nurse Coordinators and Director will perform Med Pass observations to ensure all meds are administered per physician orders.