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: Jan. 3, 2020

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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

An unannounced 60 day monitoring inspection was conducted by the Licensing Inspector from the Eastern Regional Office on 01-03-2020 from 8:25 AM to 5:13 PM. There were 33 residents in care at the time of the inspection. A tour of the facility was conducted and water temperatures were sampled. Lunch and an activity were observed. A medication pass observation was conducted with 2 residents and a spot check of the medication care was completed. 6 resident records and 3 staff records were reviewed. The criminal background checks and sworn disclosures on all staff were reviewed. The following was also reviewed: activity calendars, menus, first aid kits (facility and van), emergency food and water supply, health care oversight, resident emergency exercise, and fire and emergency evacuation drills. The facility does not currently have a dietary oversight and the emergency preparedness review is in progress. The following was discussed with the Administrator: ISP's regarding outcome dates, posting of menus, and the emergency food and water supply as the facility's census continues to increase. The facility received violations "under" Personnel, Admission, Retention, and Discharge of Residents, Resident Accommodations and Related Provisions, and Emergency Preparedness. The areas of non-compliance were discussed with the Administrator throughout the inspection. 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, 02-02-2020.

Violations:

Standard #:	22VAC40-73-1120-B
Description:	Based on record review and interview, the facility failed to ensure there are at least 21 hours of scheduled activities available to the residents on the special care unit each week. Evidence: 1. Staff #1 provided a copy of the November and December 2019 activity calendars for the special care unit (Mary B?s). The activity calendars did not document at least 21 hours of scheduled activities available to the residents during the following weeks: 11-03-2019 through 11-09-2019 (15 hours); 11-10-2019 through 11-16-2019 (15.5 hours); 11-17-2019 through 11-23-2019 (14 hours); 11-24-2019 through 11-30-2019 (14 hours); 12-01-2019 through 12-07-2019 (14.5 hours); 12-08-2019 through 12-14-2019 (14.5 hours); 12-15-2019 through 12-21-2019 (16.5 hours); and 12-22-2019 through 12-28-2019 (16 hours). 2. During interview, staff #1 acknowledged the facility did not have 21 hours of scheduled activities available to the residents during the aforementioned weeks.
Plan of Correction:	*The Life Enrichment personnel/BFMs were educated to include a review of the regulations to assure that the required elements of the monthly Activity Calendars were incorporated into each monthly calendar. *The community/Branch now uses a new format for the calendars that includes a key/legend at the bottom of the calendar indicating how much time is allotted for each activity on Mary B?s, our secured memory care unit, to assure that we meet or exceed the minimum standards. *The calendar will be reviewed, prior to the beginning of the next month, to assure that all required elements of that calendar are programmed, as required.
Standard #:	22VAC40-73-120-B
Description:	Based on record review and interview, the facility failed to ensure all staff are trained in the relevant regulations regarding the rights and responsibilities of residents. Evidence: 1. During staff record review with staff #1, staff #4, staff #5, and staff #6 were hired on 10-07-2019. The rights and responsibilities of residents reviewed with staff #4, staff #5, and staff #6 did not include the current resident rights required by the Virginia Department of Social Services (VDSS); and only included 19 out of 20 resident rights. Staff #1 could not locate and or/ provide documentation that the required 20 rights and responsibilities of residents were reviewed with the aforementioned staff. 2. During interview, staff #1 acknowledged staff #4, staff #5, and staff #6 did not review the current rights and responsibilities of residents required by the VDSS.
Plan of Correction:	*The community/Branch immediately checked to assure that the paper version used at the time of admission with residents and posted within the community was the most current version. *The community/Branch then notified the appropriate Branch Support department that the ?on-line? version, being used at the time of hire, was the previous version and needed to be updated. *The community/Branch reviewed the most current version of the ?Rights and Responsibilities of Residents in Assisted Living Facilities (VA)? with all current personnel/BFMs and retained documentation of such in their personnel files.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview, the facility failed to ensure the comprehensive individualized service plan (ISP) included a description of the residents identified needs. Evidence: 1. During resident record review with staff #1 and staff #2, 2 out of 6 ISP's reviewed did not include a description of the resident?s identified needs: A. Resident #2?s physical examination dated 11-18-2019 documented the resident has an allergy to Ampicillin; however, the ISP dated 11-26-2019 did not include a description of the Ampicillin allergy. B. Resident #4?s Uniform Assessment Instrument dated 11-27-2019 documented the resident needs mechanical and physical assistance with toileting; however, the ISP dated 11-29-2019 did not include the type of mechanical device needed for toileting. 2. During interview, staff #1 and staff #2 acknowledged resident #2 and resident #4?s ISP?s did not include a description of the resident?s aforementioned needs.
Plan of Correction:	*Residents #2 & #4 had their UAI and ISP reviewed and updated to assure that both were accurate. All corrections will be notated by date/initials in different ink color *All current residents will have their UAI and ISPs reviewed and updated to assure that they are accurate. All corrections will be notated by date/initials in different ink color. *At the time of required review/reassessment, or with a significant change, the UAI and ISP will be audited together by 2 personnel trained to complete both documents to assure that both are current and accurate.
Standard #:	22VAC40-73-860-I
Description:	Based on observation and interview, the facility failed to ensure cleaning supplies are stored in a locked area. Evidence: 1. At approximately 12:15 PM, a cleaning cart was observed on the assisted living unit near room #401 and the door that leads to the special care unit. The cleaning cart was left unattended and a bottle of furniture spray polished was observed on top of the cart. In addition, a compartment on the cleaning cart was left unlocked and contained a bottle of ?Windex?, ?Fabuloso?, and ?Orange Force Multi-Surface Cleaner Degreaser.? 2. At approximately 12:17 PM staff #3 approached the cleaning cart and acknowledged that the cleaning supplies were left unattended and were not stored in a locked area.
Plan of Correction:	*All cleaning products were immediately secured on the housekeeping cart. *All locking mechanisms on the cleaning cart were inspected to assure that they were in working order. *Housekeeping personnel/BFM was re-educated on the requirement that all chemicals and cleaning supplies be kept in either full view or locked/secured within the cleaning cart when not in use. *Safety inspections of the cleaning cart will be conducted & documented daily for 2 weeks and then weekly thereafter, during times of use, as a part of our routine safety inspections.