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 13, 2020 , July 14, 2020 and July 15, 2020

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

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 07-13-2020 and concluded on 07-15-2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 55. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, criminal background checks and sworn disclosures of newly hired staff, staff schedules, fire drills, fire and health inspection reports, dietary oversight, and healthcare oversight. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review and interview, the facility failed to ensure two out of four physical examinations reviewed contained the resident?s address, telephone number, or date of the physical examination. Evidence: 1. Resident #1?s physical examination was signed by the physician on 02-14-2020. The physical examination did not include the date of exam, resident?s address, or telephone number. 2. Resident #2?s physical examination dated 02-28-2020 did not include the resident?s address or telephone number. 3. During interview, staff #1 acknowledged resident #1 and resident #2?s physical examinations did not include the required information.
Plan of Correction:	The insufficiency will be corrected as follows: - Resident #1?s physical examination forms has been corrected on 7/23/2020 to reflect the resident?s address, or telephone number. - Resident #2?s is no longer a resident here. The following measures will be taken to ensure problems do not occur again: - On all new resident?s physical examinations will be reviewed by the administrative staff (Nurse Coordinators/ED) to ensure all parts of the physical examination forms are filled completely. - Director will randomly check 10 residents physical examination forms over 30 days. Persons responsible to implement and monitor corrective measure to ensure compliance: - Director/Nurse Coordinator
Standard #:	22VAC40-73-450-C
Description:	Based on record review, and interview, the facility failed to ensure the Individualized Service Plan (ISP) included a description of identified needs based on the Uniform Assessment Instrument (UAI) and physician?s orders. Evidence: 1. The following ISP?s did not include a description of the residents? identified needs: A. Resident #1?s current UAI dated 03-25-2020 documented the need for mechanical assistance with toileting and transferring, and mechanical assistance with supervision by staff with walking; however, the current ISP dated 03-27-2020 did not include documentation of the type of mechanical device that is needed for toileting or transferring and did not include the type of supervision that would be provided by staff. Additionally, a physician?s order dated 03-09-2020 documented SLP eval and treat. The therapy speech pathology ?Progress Notes? dated 04-21-2020 documented ?patient will be seen 3 visits per week for a total of 90 days? Certification Period from 03-17-2020 to 06-14-2020.? The ISP did not document speech pathology services being provided. B. Resident #2?s current UAI dated 04-16-2020 documented the need for mechanical and physical assistance with dressing, toileting, and transferring; however, the current ISP dated 04-17-2020 did not include documentation of the type of mechanical device that is needed for dressing, toileting, or transferring. C. Resident #3?s current UAI dated 02-06-2020 documented the need for mechanical and physical assistance with bathing; however, the current ISP dated 02-06-2020 did not include documentation of the type of mechanical device that is needed for bathing. Additionally, a current physicians order dated 06-11-2020 (original order dated 04-25-2019) documented ?02- PRN nasal canula as needed 2L;? however, the resident?s need for oxygen was not documented on the ISP. D. Resident #4?s current UAI dated 04-21-2020 documented the need for mechanical and physical assistance with dressing and transferring, and mechanical assistance with supervision by staff with toileting; however, the ISP dated 04-21-2020 did not include documentation of the type of mechanical device that is needed for dressing, transferring or toileting. 2. Staff #1 acknowledged resident #1, resident #2, resident #3, and resident #4?s ISP?s did not include a description of the residents? aforementioned needs.
Plan of Correction:	The insufficiency will be corrected as follows: - Resident #1?s ISP has been corrected on 7/23/2020 to include type of mechanical device that is needed for toileting, transferring, and include the type of supervision that would be provided by staff. ISP has been corrected to include speech pathology services being provided. - Resident #2?s is no longer a resident here. - Resident #3?s ISP has been corrected on 7/23/2020 to include mechanical device for bathing. ISP has been corrected to include oxygen. - Resident #4?s ISP has been corrected on 7/23/2020 to include type of mechanical device that is needed for mechanical device that is needed for dressing, transferring or toileting. The following measures will be taken to ensure problems do not occur again: - On all new, annual or change of conditions, ISPs will be reviewed by the administrative staff (Nurse Coordinators/ED) to ensure all needs are addressed. - Director will perform 10 random audits of ISPs over 60 Days. Persons responsible to implement and monitor corrective measure to ensure compliance: - Director/Nurse Coordinator
Standard #:	22VAC40-73-650-B
Description:	Based on record review and interview, the facility failed to ensure physician orders, both written and oral, for administration of all prescription and over-the-counter medications, identified the diagnosis or specific indications for administering each drug. Evidence: 1. Resident #1?s current signed physician?s orders dated 06-11-2020 did not include the diagnosis or specific indications for administering Acetamin 500mg or Clonazep 0.25mg. 2. Resident #2?s current signed physician?s orders dated 06-08-2020 did not include the diagnosis or specific indications for administering Amlodipine 2.5mg, Aspirin 81mg, Folic Acid 1mg, Pravastatin 40mg, or Vitafus Multi-vite Gummy. 3. Staff #1 acknowledged resident #1 and resident #2?s aforementioned physician?s orders did not include the diagnosis or specific indications for administration of the aforementioned drugs.
Plan of Correction:	The insufficiency will be corrected as follows: - Resident #1 current signed physicians orders has been corrected on 7/23/2020 to include diagnosis for Acetamin 500mg and Clonazep 0.25mg - Resident #2 is no longer a resident here. The following measures will be taken to ensure problems do not occur again: - Nurse Coordinator will randomly perform audit on all residents? current signed Physicians Orders to ensure there are diagnosis for each drug over 30 days. - On all new resident?s admitting physician orders will be reviewed by the administrative staff (Nurse Coordinators/Director) to ensure there is a diagnosis for each drug. Persons responsible to implement and monitor corrective measure to ensure compliance: - Director/Nurse Coordinator