VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bickford of Virginia Beach
2629 Princess Anne Road
Virginia beach, VA 23456
(757) 821-0198

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: Oct. 25, 2019

Complaint Related: No

Areas Reviewed:

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

Comments:

An announced initial inspection was conducted by the Licensing Inspector from the Eastern Regional Office on 10-25-2019 from 10:05 AM to 1:03 PM. There were no residents in care at the time of the inspection. A tour of the facility was conducted. Call bells, exit doors, and the emergency evacuation maps were reviewed. Measurements were taken for each model as well as the end rooms, and the doors and protective devices on windows were reviewed on the special care unit. Water temperatures were also sampled. The following was discussed with the Divisional Director of Operations during the inspection: Posted emergency evacuation maps; water temperatures; and windows on the special care unit. The facility received violations "under" Buildings and Grounds, Emergency Preparedness, and Addition Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. 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, 11-16-2019.

Violations:

Standard #:	22VAC40-73-1150-B
Description:	Based on observation and interview, the facility failed to ensure the protective devices on the residents bedroom windows prevented the windows from being opened wide enough for a resident to crawl through. Evidence: 1. During the tour of the special care unit with staff #1, the orange triangular protective device located on the left window in room #516 did not prevent the window from being opened wide enough for a resident to crawl through. 2. During interview, staff #1 acknowledged the protective device did not work on the left window in room #516, and that the window was wide enough for a resident to crawl through.
Plan of Correction:	The insufficiency will be corrected as follows: ? The windows in secured unit were secured with a permanent protective device to comply with the standard on 11/4/19. The following measures will be taken to ensure the problem does not recur: ? Staff will notify maintenance and director immediately if any window in secured unit is not functioning properly ? Windows will be checked apartment inspection upon admission ? Windows in secured unit will be checked on quarterly Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? Maintenance Coordinator and Housekeeper ? Director
Standard #:	22VAC40-73-860-G
Description:	Based on record review and interview, the facility failed to ensure hot water at taps available to residents is maintained within a range of 105?F to 120?F. Evidence: 1. During the tour of the facility with staff #1, the hot water taps sampled in three out of the five bathrooms were not within the required range: 135.9?F (Room #102), 137.5?F (Room #306), and 135.3?F (Room #401). 2. During interview, staff #1 acknowledged the aforementioned temperatures from the hot water taps in rooms #102, #306, and #401.
Plan of Correction:	The insufficiency will be corrected as follows: ? Water heater temperature was turned down to 120 degrees on 10/25/19 The following measures will be taken to ensure the problem does not recur: ? Check water temperatures and ensure within range monthly. Kitchen, Laundry Room and 3 resident apartments (105-120F) - check 1 resident apartment per hallway/floor ? Ensure hot water circulating pump is running quietly monthly ? Water temperature log to be kept up to date Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? Maintenance Coordinator ? Director
Standard #:	22VAC40-73-960-B
Description:	Based on observation and interview, the facility failed to ensure the fire and emergency evacuation drawing was posted in a conspicuous area and showed secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes, and fire extinguishers, as appropriate. Evidence: 1. During the tour of the facility with staff #1, the fire and emergency evacuation maps observed were posted near rooms #214, #307, and #401. The drawings did not include the secondary escape routes, areas of refuge, assembly areas, telephones, or fire alarm boxes. 2. When asked if the fire and emergency evacuation maps near rooms #214, #307, and #401 were the only drawings posted in the facility, staff #1 indicated the main fire and emergency evacuation map was posted near the front of the facility. Staff #1 retrieved the main fire and emergency evacuation drawing located in the front office; however, the drawing was not posted in a conspicuous area. In addition, the drawing did not include the secondary escape routes, assembly areas, telephones, fire alarm boxes, or fire extinguishers. 3. During interview, staff #1 acknowledged the aforementioned fire and emergency evacuation drawings did not include the required information.
Plan of Correction:	The insufficiency will be corrected as follows: ? The fire and emergency evacuation map was re-posted with the secondary escape routes, areas of refuge, assembly areas, telephones and fire alarm boxes on 10/25/19 The following measures will be taken to ensure the problem does not recur: ? Maps will remain posted in conspicuous areas in the branch ? Location of maps to be checked monthly Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? Maintenance Coordinator ? Director