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: July 22, 2021 , Oct. 1, 2021 and Oct. 27, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

A non-mandated monitoring inspection was initiated on 7-22-21 and concluded on 11-1-21. The Registered Nurse Coordinator was contacted by telephone to conduct the inspection. The licensing inspector emailed the Registered Nurse Coordinator a list of documentation required to complete the inspection. The licensing inspector conducted a joint on-site observation at the facility on 10-1-21. The evidence gathered during the inspection support non-compliance with standards or law, and violations were issued.

Violations:

Standard #:	22VAC40-73-310-H
Description:	Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals in the assisted living with any conditions or care need prohibited by the regulation and Code of Virginia. Evidence: 1. Resident #1?s July 2021 medication administration record (MAR) documented resident prescribed Buspirone; prescriber?s order signed and dated 7-8-21. 2. Resident #3?s July 2021 MAR documented resident prescribed Seroquel; prescriber?s order signed and dated 7-18-21. 3. On 10-27-21 a request for the treatment plan for the psychotropic medications were requested but not received. 4. On 11-1-21, staff #1 acknowledged treatment plan for resident #1?s Buspirone and resident #3?s Seroquel was not provided for review.
Plan of Correction:	*Resident #1 & resident #3 did receive a Psychoactive Medication Treatment Plan for their medications referenced. *A 100% audit was conducted of all resident medication profiles to assure that any medication requiring a Psychoactive Medication Treatment Plan was obtained from their provider and filed in their record. *As a part of the Weekly Med Audits, a Psychoactive Medication Report will be printed and used for audit purposes to assure that all Psychoactive Medication Orders have an appropriate Treatment Plan. *The findings from those audits will be monitored weekly and the results reported for Divisional Review. Responsible Party: RNC/ACC/Divisional Director Target Date: 11/5/2021 & ongoing
Standard #:	22VAC40-73-680-D
Description:	Based on document review and staff interview, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. Resident #2?s May 2021 medication administration record (MAR) documented Nystatin powder, ?apply topically four times a day for 7 days?. The mar was documented by staff on 5-10- through 5-15-21. A review of the nurse?s notes dated 5-8-21 at 20:00 p.m. documented, the new order was called to a local pharmacy. Nurse?s notes dated 5-9-21 at 10:00 a.m. documented, ?medications p/u from pharmacy. Faxed written orders call to facility assigned pharmacy last night and delivered to the Branch. 1 st dose given upon arrival to the Branch after checking in?. However, the MAR did not document dosages for 8:00 a.m.; 12:00 p.m.; 4:00 p.m.; and 8:00 p.m. on 5- 8-21 neither on 5-9-21. The MAR documented the first dosage on 5-10-21 at 8:00 a.m. 2. Resident #2?s Nystatin documentation on May 2021?s MAR reviewed with staff #1 and staff #2 on 10-27-21.
Plan of Correction:	*Resident #2?s Provider was notified about the number of documented doses of Nystatin powder that was administered. There were no new orders. *All prescription orders intended to treat a short-term acute condition will be faxed to the pharmacy to be filled, as ordered. Once the medication is received, the Branch will notify the pharmacy that it was received and inform them of when the 1st dose will be administered so that the start and stop dates can be profiled to assure that the date range allows for all ordered doses to be administered. *The RNC and ACC to conduct a 24hr. audit after the receipt of all short-term acute condition medication orders to assure that the medication arrived, that administration has begun, has been documented, and has been charted. They will also review the start and stop dates to assure that the date range allows for all ordered doses to be administered as prescribed. *The findings from those audits will be monitored weekly and the results reported for Divisional Review. Person responsible: RNC/ACC/Divisional Director Target completion date: 11/5/2021 & ongoing
Standard #:	22VAC40-73-680-I
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the medication administration record (MAR) included all required information. Evidence: 1. Resident #2?s May 2021 medication administration record (MAR) documented Fluconazole, however, the MAR did not include a diagnosis, condition, or specific indications for administering the drug. Resident?s July MAR documented Zamzaric, however, the MAR did not include a diagnosis for the drug. 2. Resident #3?s July 2021 MAR documented resident to wear Ted Hose, ?on in the morning off at bedtime?, however, the MAR did not include a diagnosis, condition, or specific indications for the use of the Ted hose. 3. On 10-27-21, discussion was conducted regarding the MARs missing the diagnosis for resident #2 and #3. 4. On 11-1-21, staff #1 acknowledged resident #2?s MAR did not include diagnosis for the aforementioned medications and resident #3?s MAR did not include diagnosis for the use of Ted Hose.
Plan of Correction:	*Residents #2 and #3 had the missing diagnosis added to their MARs. *A 100% audit was conducted by the RNC to assure that all resident medications had an appropriate diagnosis listed on the MAR. *All medications on the MARs that are missing a diagnosis will have the appropriate diagnosis hand-written on a printed MAR by the RNC or ACC, next to that medication, that will then be faxed to the Pharmacy to be profiled on the MAR. *That faxed copy will be retained and used during the Weekly Med Audits to assure that the proper diagnosis was added by the Pharmacy. *The findings from those audits will be reviewed weekly and the DFGs and the results reported for Divisional Review. Responsible Party: RNC/ACC/Director/Divisional Director Target Date: 11/19/2021 & ongoing
Standard #:	22VAC40-73-870-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the interior of the building was maintained in good repair and kept clean and free of rubbish. Evidence: 1. On 10-1-21 during a tour of the facility with staff #1, the carpet in front of the nursing station on the assisted living unit was observed with a dark stain area approximately 7 x 5 inch. The carpet in the hallway in front of room #216 was also observed to have several dime sized spots and an approximate 1 in wide x 18 in long stain in the carpet. 2. Staff #1 acknowledged the carpet stains during the tour on 10-1-21.
Plan of Correction:	*It is always the expectation of this Branch to respond to any spills/staining on the carpet as timely as possible once identified. *Staff #1 had the carpet in front of the AL Nurses Station and in front of apartment #216 cleaned immediately upon the Inspector?s exit and emailed photos to the Inspector that evening showing that the areas in question were cleaned and that there were no stains remaining. *Staff #1 purchased a portable carpet cleaner, with instructions, to be used by our BFMs (staff) to address soiled areas on the carpet. If additional cleaning is required, it will be noted on the Maintenance Log to be addressed by Housekeeping. *Directing Family Group (Management Team) to observe the carpet during routine rounds for soiled areas and note any areas needing to be cleaned in the Maintenance Log. Responsible Party: RNC/ACC/Director Target Date: 10/1/2021 & ongoing
Standard #:	22VAC40-73-930-A
Description:	Based on observation and staff interview, the facility failed to ensure when the call bell/signaling device is pulled, direct care staff is alert of the need for assistance. Evidence: 1.On 10-1-21 during rounds on the facility?s safe, secure unit, the call bell was pulled in room #502 at 9:47 a.m. At 9: 57 a.m., there was no staff response. Staff #2 and the inspectors were informed that staff #5 was assigned. However, it was later learned that staff #5 did not have a pager and therefore could not respond to the call bell for room #502. 2. Staff #2 acknowledged staff could not respond to the call bell because staff #5 did not have a pager.
Plan of Correction:	*Staff #1 assured that all pagers were in proper working order, labeled, and available so that each BFM (staff member) assigned to Resident Care had a pager to use to respond to call bells. *Staff #2 reviewed the pager/call bell policy immediately with those on duty at the time of the Inspection on 10/1/21. This was also reviewed with all BFMs, who provide Resident Care, at a Mandatory Nursing Meeting/In-service held on 10/27/21 *The BFM Designated In Charge on each shift is responsible for overseeing that the pagers are being worn and used to respond to resident call bells. *The Directing Family Group (Management Team) will conduct announced call bell audits to monitor for timely response and will also observe to assure that all BFMs responsible for Resident Care are wearing the pagers, per policy. *The findings from those audits will be reviewed weekly by the DFGs and the results reported for Divisional Review. Responsible Party: RNC/ACC & Designee/Director/Divisional Director Target Date: 10/27/2021 & ongoing