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: Aug. 3, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 EMERGENCY PREPAREDNESS

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: 08/03/2022 from 1:03 pm to 2:30 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 7/31/2022 regarding allegations in the area(s) of: Part VI. Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 39 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: 2 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 #:	22VAC40-73-150-C
Description:	Based on record review and interview, the facility failed to implement policies, procedures, and services established by the facility. Evidence: 1. Resident #1 admitted to the facility on 6/4/22. The Report of Resident?s Physical Examination (dated 5/5/22), Resident Face Sheet, Individualized Service Plan (dated 6/4/22) for Resident #1 indicate the resident as a full code. On 7/30/22, Resident #1 was found unresponsive in their apartment and CPR was not conducted. The facility?s procedures titled ?Unresponsive Resident? states ?after you have called 9-1-1, begin CPR, unless appropriate DNR orders are in place.? 2. Staff #1 and Staff #2 acknowledged their procedures in the aforementioned incident were not followed.
Plan of Correction:	All residents, regardless of code status, shall receive care appropriate to their condition and needs, including measures essential to comfort and well-being. In the absence of a DoNotResuscitate order (DNR), a Resident shall receive all resuscitative efforts. All Staff have been educated on following residents documented request for CPR/DNR to ensure residents wishes are carried out.