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: July 10, 2019 and July 11, 2019

Complaint Related: No

Areas Reviewed:

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 22VAC40-90 Background Checks for Assisted Living Facilities

Technical Assistance:

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Comments:

An unannounced renewal inspection was conducted on 7-10-19 (3:05 p.m to 4:35p.m )and 7-11-19 (8:50a.m to 5:50p.m.) The facility is full to capacity. Eight resident records and five staff records were reviewed . Three residents were observed receiving their morning medications. Interview were conducted with families ,residents , and staff. The lunch meal posted and served was baked ziti, salad green beans, harvest soup, fruit parfait, bread. There is an electronic menu board posted in the dining room. On 7-11-19 live entertainment was provided. The was discussion about training requirements . The facility has a generator fueled by natural gas that is tested on Sundays and Tuesdays . The generator is service quarterly. 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 7-28-19 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

Violations:

Standard #:	22VAC40-73-210-B
Description:	Based on record review and interview the facility failed to ensure , to of the four professional or certified nurses aides records reviewed in the record sample had attended at least 12 hours of training annually. Evidence 1. During a review of the staff records with staff #1 , on the day of the inspection (7-11-19,) the inspector found staff # 5, hired 4-12-18 had 5.45 hours of documented training on file . Staff # 7 hired 7-10-17, had 9.5 hours of documented training on file . 2. Staff #1 search the file and confirmed the staff did not have the twelve hours of annual training required .
Plan of Correction:	The insufficiency will be corrected as follows: ? Staff #1 has been caught up on the annual 12 hours of training on 7/12/19 The following measures will be taken to ensure the problem does not occur again: ? Director and or Nurse Coordinators will perform monthly audits to ensure staff has completed required training. ? Director will perform 10 random staff audit for completion of required staff training over the next 60 days. Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? ED/Nurse Coordinators
Standard #:	22VAC40-73-220-B
Description:	Based on record review and interview the facility failed to ensure when a private duty personnel who was not an employee of a licensed home care organization, provided direct care or companion services to a residents in an assisted living facility the following applied: Obtain, in writing, information on the type and frequency of the services to be delivered to the resident by private duty personnel, review the information to determine if it is acceptable, and provide notification to whomever has hired the private duty personnel regarding any needed changes. Evidence 1. During interview the inspector learned ,the private duty staff providing care to resident # 1 ,worked Monday -Friday from 8a.m to 4 p.m. 2. On day one of the inspection while reviewing the resident's file with staff #1, , the inspector found no written information on the type and frequency of the services provided by the private duty. 3. Staff #1 and #2 acknowledged that information was not on file.
Plan of Correction:	The insufficiency will be corrected as follows: ? Resident #1 file has been updated to reflect the type and frequency of services provided by the private duty care on 7/12/19 The following measures will be taken to ensure the problem does not occur again: ? Nurse Coordinators will audit all resident charts that are receiving private duty care. ? ED will perform 5 random audits of residents with private duty care over 60 Days. Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? ED/Nurse Coordinators
Standard #:	22VAC40-73-440-H
Description:	Based on record review the facility failed to ensure one of eight residents had an annual reassessments using the UAI, to determine whether a resident's needs could continue to be met by the facility and whether continued placement in the facility was in the best interest of the resident. Evidence 1. During the review of the UAIs with staff #1 and #2, the inspector found resident #6's last UAI update was on 1-27-18. 2. Staff #2 checked the file and confirmed the UAI had not been updated annually .
Plan of Correction:	The insufficiency will be corrected as follows: ? Resident #6 annual UAI has been completed and updated on 7/12/19 The following measures will be taken to ensure the problem does not occur again: ? On all new, annual or change of conditions, UAIs will be reviewed by the administrative staff (Nurse Coordinators/ED) to ensure all needs are addressed. ? ED will perform 10 random audits of UAIs over 60 Days. Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? ED/Nurse Coordinators
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview one of seven residents in the record sample did not have a comprehensive individualized service plan (ISP) completed within 30 days after admission. Evidence 1. While reviewing records with staff # 1and #2, the inspector found resident #7 admitted 4-30-19 had an ISP marked initial dated 4-30-19. 2. Staff # 2 checked the file and confirmed no other ISP could be located at the time of the inspection.
Plan of Correction:	The insufficiency will be corrected as follows: ? Resident #7 30 day ISP was printed out from saved drive and had resident/legal representative sign. The following measures will be taken to ensure the problem does not occur again: ? Nurse Coordinators will complete 30 day ISPs after the initial move in date for all new resident admissions. ? ED will check to ensure 30 day ISPs are completed after the initial move in date for all new resident admissions. ? ED will perform 10 random audits of resident?s 30 days after admission ISPs over 60 Days. Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? ED/Nurse Coordinators
Standard #:	22VAC40-73-870-A
Description:	Based on observation and interview the facility failed to ensure the interior of all buildings was maintained in good repair and kept clean and free of rubbish. Evidence 1. During a tour of the building on day two of the inspection(7-11-19), around 10:00a.m. with staff # 1, the inspector observed the wall next to resident #2's bed splattered and marred with dried and semi dried mucous and saliva. Later that same day at 5:04p.m , while with the maintenance director the wall next to resident #2's bed remain in the same condition found seven hours earlier. Also while with the maintenance director the inspector also observed hanging over the grab bar next to resident #2's toilet a urinal stain with a black substance marbling along the side urinal and partially covering the bottom of the urinal . 2. Also while on tour with staff # 1, the inspector observed behind resident #3's recliner chair , a hole in the wall about 7x8 that partially exposed the wood framing inside the wall . The resident's floor was speckled with what appeared to be crumbs and paper fibers. 3. While in resident's #4's room with staff # 3, during the medication observation pieces of popcorn were observed all about the floor . 4. During a tour of the secured unit with staff #1 ,the inspector observed a crack in the wall behind resident # 5's wooden chair about 4 to 5 inches long and about 3/4 of an inch deep.
Plan of Correction:	The insufficiency will be corrected as follows: ? Resident #2 apartment has external cleaning service comes in twice a week to deep clean on every Monday and Friday. It will be increased to 3 times a week. In addition to the external service, Bickford will provide light housekeeping daily to ensure cleanliness of the room. ? Resident #3 hole behind the recliner chair has been fixed on 7/12/19 ? Resident #4 will have light daily housekeeping to ensure cleanliness of room. ? Resident #5 crack in the wall has been fixed 7/12/19. The following measures will be taken to ensure the problem does not occur again: ? Weekly room checks by housekeeping will be performed to check for maintenance work and cleanliness. ? Nurse Coordinators will include training for staff on light housekeeping on the next all staff in-service on 7/30/19. ? Director will randomly perform oversight 5 room checks weekly for the next 6 weeks. Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? ED/Maintenance Director/Housekeeper