VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bickford of Chesapeake
361 Great Bridge Boulevard
Chesapeake, VA 23320
(757) 819-9500

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: June 27, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/27/2022 from 9:38 am to 5:08 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 38 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1110-A
Description:	Based on record review and interview, the facility failed to ensure prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee determine whether placement in the special care unit is appropriate. Evidence: 1. Resident #6 and Resident #7 did not have documentation of the determination and justification on whether placement in the special care unit is appropriate by the licensee, administrator, or designee. 2. Staff #1 acknowledge both Resident #6 and Resident #7 did not have documentation of the determination and justification on whether placement in the special care unit is appropriate by the licensee, administrator, or designee.
Plan of Correction:	Prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, Administrator and Nurse Coordinator will determine whether placement in the special care unit is appropriate. A signed letter will be placed in resident chart.
Standard #:	22VAC40-73-250-C
Description:	Based on record review and discussion, the facility failed to maintain personal and social data on staff to include verification that the staff person has received a copy of his current job description. Evidence: 1. Staff #6?s record does not include verification that the staff person has received a copy of their current job description. 2. Staff #1 acknowledged the aforementioned item was not included in Staff #6?s record.
Plan of Correction:	All Staff will receive a copy of their job description and verify with signature at time of hire.
Standard #:	22VAC40-73-250-D
Description:	Based on record review and discussion, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. There is no documentation of a completed initial tuberculosis risk assessment for Staff #5 (hire date 5/19/22). 2. Staff #1 acknowledged the TB risk assessment for Staff #5 was not completed.
Plan of Correction:	Form was left incomplete. On or within the first seven days prior to the first day of work at the Branch, all Bickford Family Members (BFMs) must have a Physician, his/her designee or Health Department Official complete the Report of TB Screening Form2 to ensure they are not infected with tuberculosis. This form will be provided to the Branch prior to the BFMs working.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff #6 (hire date 4/13/22) works as direct care staff and does not have documentation of a current certification in first aid in their staff record.
Plan of Correction:	All Staff will provide proof of cpr and first aid upon hire. Failure to provide accredited certification will result in staff member obtaining within 30 days of hire date.
Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure a resident have a completed physical examination by an independent physician. Evidence: 1. The Report of Resident?s Physical Examination for Resident #1 and Resident #5 does not include the date of physical exam.
Plan of Correction:	Audit conducted on all current residents by nurse coordinator. Nurse Coordinator will review physical examinations for accuracy prior to admission.
Standard #:	22VAC40-73-550-G
Description:	Based on record review and discussion, the facility failed to obtain written acknowledgment of the receipt and review of the rights and responsibilities of residents in assisted living facilities with the resident's, his legal representative's or responsible individual. Evidence: 1. Resident #6 did not have written acknowledgment of the receipt and review of the rights and responsibilities of residents in assisted living facilities with the resident's, their legal representative's or responsible individual. 2. Staff #1 acknowledged there was no documentation of a review of resident rights for Resident #6.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-650-B
Description:	Based on record review and discussion, the facility failed to ensure physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. The following medications on Resident #2?s MAR did not include a diagnosis: Donepezil 10mg tab, Fluticasone Spr 50mcg, Lisinopril 20mg tab, Omega-3 fish 1000mg cap, Omega-3-Acid 1gm cap, Preservision AREDs 2 caps, Turmeric 500mg cap, Vit D 50 mcg (2000IU) tabs, Vitamin B-12 500 mcg tab, and Vitamin C 500 mg tab. 2. The following medications on Resident #4?s MAR did not include a diagnosis: Furosemide 40mg tab and Loratadine 10mg tab. 3. The following medications on Resident #5?s MAR did not include a diagnosis: Amlodipine 5mg tab, Bupropn HCL 150mg XL tab, Escitalopram 20mg tab, Omeprazole 20mg cap, Pot Chloride 10meq ER cap, and Trazodone 100mg tab. 4. The following medications on Resident #7?s MAR did not include a diagnosis: Acetamin 5000mg tab, Bone Strength tabs, Docusate Sod 100mg tab, and Quetiapine 25mg tab (2 separate orders). 5. The following medications on Resident #9?s MAR did not include a diagnosis: Budesonide 3mg DR cap, Metoprol TAR 25mg tab, Nifedipine 30mg ER tab, Probiotic cap, Vyzulta Sol 0.024%.
Plan of Correction:	Audit conducted on all current resident Mar's by Nurse Coordinator. Nurse Coordinator to ensure all resident MAR's include diagnosis for prescribed medications.
Standard #:	22VAC40-73-720-A
Description:	Based on record review, the facility failed to ensure a valid written Do Not Resuscitate (DNR) order has been issued by the resident's attending physician; and that the written order is included in the individualized service plan. Evidence: 1. Upon review of Resident #2?s record, the Physical Examination (dated 5/12/22) indicates the code status of the resident as a DNR. The resident does not have a signed DNR order or Durable DNR in their record. 2. Upon review of Resident #5?s record, there are inconsistencies in regards to the resident?s code status. The ISP (dated 6/18/22) and admitting Physician?s Admissions orders (4/26/22) indicate Resident #5 is a Full Code; however, facility?s ?Resident Emergency Code Status? form (date 4/19/22) signed by the resident and the last physician order sheet indicate the resident is a DNR. Resident #5?s Resident Face Sheet is blank next to the code status.
Plan of Correction:	Upon Admission and during routine chart review, Nurse Coordinator will ensure DNR status is consistent on all documents in Resident chart.
Standard #:	22VAC40-73-980-B
Description:	Based on observation, the facility failed to ensure a first aid kit for the building contain items as identified in the standard. Evidence: 1. The building first aid kit did not include triangular bandages. 2. Staff #2 acknowledged the aforementioned item was not included in the first aid kit.
Plan of Correction:	Not available online. Contact Inspector for more information.