VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bridgeforth Manor
2683 Washington Avenue Ext.
Victoria, VA 23974
(434) 696-3461

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Nov. 18, 2019

Complaint Related: No

Areas Reviewed:

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 63.2 Protection of adults and reporting. 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

An unannounced monitoring inspection was conducted by 1 licensing staff on 11/18/19 from approximately 8:00 a.m. - 12:30 p.m. There are currently 5 residents in care at the facility. One resident was present during the inspection. During the inspection, a tour of the facility was conducted, a sample of 4 resident and 3 staff records were reviewed, facility documentation was reviewed, facility required posting's were reviewed, first aid kit and emergency food/water supplies were checked, activity was observed, medication pass was observed, medication administration records and physician orders were reviewed and staff and resident interviews were conducted. An exit meeting was held with the administrator. Violations were cited during this inspection. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the Inspector within 10 days. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 1) steps to correct the non-compliance 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). Please contact me by e-mail at T.Lesley@dss.virginia.gov if further assistance is needed.

Violations:

Standard #:	22VAC40-73-210-B
Description:	Based on review of staff records and facility documentation, the facility failed to ensure that all direct care staff attend at least 18 hours of training annually. Evidence: 1) Staff #1 (hire date 10/18/00) had a total of 16 training hours completed for the annual training period. 2) Staff #2 (hire date 10/26/00) had a total of 10 training hours completed for the annual training period.
Plan of Correction:	Administrator will ensure that all direct care staff attend at least 18 hours of training annually.
Standard #:	22VAC40-73-210-F
Description:	Based on the review of staff records, facility documentation and staff interview, the facility failed to ensure that at least two of the required annual hours of training shall focus on infection control and prevention. Evidence: 1) Staff #1 (hire date 10/18/00), staff #2 (hire date 10/26/00) and staff #3 (hire date 9/10/00) did not have at least 2 hours of infection control and prevention training hours completed within the annual training period. 2) Staff #3 confirmed during interview that infection control training had not been completed.
Plan of Correction:	Annual hours of training with focus on infection control and prevention will be done for the annual training period.