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: July 22, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 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: 07/22/2022 from 10:00 am to 11:23 am. 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: 1 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-1100-A
Description:	Based on record review, 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 #1 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:	Chart audit has been conducted for all resident's residing in special care unit. Determination of Justification form will be completed for all new admissions.
Standard #:	22VAC40-73-1150-A
Description:	Based on observation, record review and interview, the facility failed to ensure doors that lead to unprotected areas be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates for residents residing in a safe, secure environment. Evidence: 1. On 7/9/22 around 12:54 p.m., Resident #1 who resides in a safe, secure environment was unable to be located. The facility reports a staff member utilized the door and it did not latch closed; however, it closed enough for the sensor to think it was closed which caused the alarm not to sound initially. The resident was located half a mile away approximately 30 minutes after they were last seen inside of the unit. The resident is believed to have fallen as the resident returned to the facility with scrapes to arms and legs and a bruise to the left eye.
Plan of Correction:	Additional Alarms installed to all exit doors in memory care with louder tone for notification. Unannounced Unwitnessed Missing Residents Drill to be conducted once per month for the next 3 months. Routine Quarterly Drills will occur as scheduled.
Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure within the 30 days preceding admission, a person have a physical examination by an independent physician to include results of a risk assessment for tuberculosis on each resident 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. Resident #1 admitted to the facility on 5/17/22; however, the risk assessment for tuberculosis (dated 5/5/22) was not completed and did not indicate the resident is considered free of tuberculosis in a communicable form.
Plan of Correction:	Within 30 days prior to move-in, all Residents will have a Physician, his/her designee or Health Department Official complete the Report of TB Screening Form 2 ensuring that the Resident is not infected with tuberculosis. This form will be provided to the Branch prior to the Resident moving in to be kept in the Resident?s medical record.
Standard #:	22VAC40-73-450-A
Description:	Based on record review, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare and be signed and dated by the licensee, administrator, or his designee (i.e., the person who has developed the plan), and by the resident or his legal representative. Evidence: 1. Resident #1 admitted to the facility on 5/17/22; however, the ISP (dated 5/17/22) is not signed by the resident or their legal representative.
Plan of Correction:	Upon Admission, ISP will be reviewed and signature obtained.