VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bickford of Spotsylvania
5000 Spotsylvania Parkway
Fredericksburg, VA 22407
(540) 898-1205

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: April 8, 2019 and April 10, 2019

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 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 SANCTIONS.

Comments:

Date of Inspection: A8 and 10, 2019 Type of Inspection: Complaint Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 44 Number of records reviewed and interviews conducted- 17 records, 7 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations:

Standard #:	22VAC40-73-40-A
Description:	Based on direct observation by the Licensing Inspector and Administrative staff, it was determined that facility staff failed to adhere to facility policies as required. Evidence: Staff A was observed in the kitchen and dining area on April 8 and 10, 2019 without the proper hair covering as required.
Plan of Correction:	All staff will be outfitted as required to ensure the compliance with food handling and food service for the residents in care.
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review and staff interview, it was determined that the facility failed to have the Individualized Service Plans (ISP) signed by residents and legal representatives as required. Evidence: Resident A had no documentation of signature on the ISP dated April 2, 2019. Resident G had no documentation of signature on the ISP dated January 3, 2019.
Plan of Correction:	All ISPs will have the appropriate signatures as required. The administrative staff will audit the records to ensure compliance.
Standard #:	22VAC40-73-550-C
Description:	Based on resident interview and staff interview, it was determined that residents were not being given the rights afforded to them as set forth in the Code (63.2-1808) Evidence: Staff A was serving meals to residents with special diets (both pureed and mechanical soft) without regard for the dignity of the resident in the presentation during mealtimes.
Plan of Correction:	All meals will be served to residents with special diets in a manner which promotes the well being and individual dignity of residents in care.
Standard #:	22VAC40-73-620-A
Description:	Based on resident record review and staff interview, it was determined that there had been no oversight of special diets every six months as required. Evidence: Staff A failed to inform the dietician of the special diets for residents in care. As a result, there was no documentation of oversight to ensure the residents nutritional needs were met.
Plan of Correction:	All residents special diets will be forwarded to the dietician for oversight as required.