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: Sept. 13, 2022 and Sept. 14, 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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/13/2022 from 8:36 am to 4:18 pm and 09/14/2022 from 10:57 am to 12:30 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: 45 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 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 #:	22VAC40-73-250-D
Description:	Based on record review, 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. The initial tuberculosis risk assessment for Staff #5 (hire date 06/15/2022) was not dated. 2. There is no documentation of a completed initial tuberculosis risk assessment for Staff #6 (hire date 06/27/2022).
Plan of Correction:	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. Staff # 6 Corrected on 9/15/22.
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 #5 and Staff #6 work as direct care staff and do not have a current certification in first aid.
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. Branch CPR & First Aid Class Scheduled for 10/20/2022
Standard #:	22VAC40-73-520-I
Description:	Based on observation, the facility failed to ensure the activity schedule for the current month be posted in a conspicuous location in the facility. The facility also failed to include all required information on the posted activity schedule. Evidence: 1. During a tour of the facility, the activity schedule posted in the safe, secure environment was for a two week period and did not include the month, date, or the time of the activities.
Plan of Correction:	Weekly Calendars Posted. Monthly Calendar corrected on 10/01/2022.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to implement their methods to prevent the use of outdated medications based off their written plan for medication management. Evidence: 1. The following expired medication was observed in the medication room at the facility: Tramadol HCL 50 mg tablets expired 07/18/2022 for Resident #10.
Plan of Correction:	Expired Medication will be removed immediately. Nurse Coordinator to complete weekly med audit. Divisional Director to conduct Branch Audit monthly for the next three months. . Corrected 9/14/2022.
Standard #:	22VAC40-73-680-D
Description:	Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. The physician order sheet signed 09/06/2022 for Resident #3 indicates medication orders for Diltiazem 240mg ER capsule (1x daily) and Lisinopril 20mg tablet (2x daily) include a parameter of hold if SBP below 115 or HR below 60. It also includes a medication order for Metoprolol 50mg ER tablet (1x daily) with a parameter of hold if SBP below 110 or HR below 60. The MAR for Resident #3 indicates on 09/07/2022 at 8 am the resident?s BP was 105/71, and Diltiazem, Lisinopril, and Metoprolol were administered. Additionally, on 09/01/2022, 09/02/2022, 09/07/2022, and 09/12/2022, per the MAR, the 4pm dose of Lisinopril was administered to Resident #3 despite their HR below 60.
Plan of Correction:	Re-Education to Med Tech's & LPN's by Nurse Coordinator: Nurse/Med Tech will select the proper Resident to pass meds to and proceed with scanning and checking the medication box on the computer. The scanning and checking will allow the Nurse/Med Tech to verify that the right medication is being given to the right Resident at the right time. Any exception will be noted with initials and physician instructions followed.
Standard #:	22VAC40-73-680-I
Description:	Based on record review, the facility failed to ensure the MAR include a diagnosis, condition, or specific indications for administering the drug or supplement. Evidence: 1. The following medication on Resident #1?s MAR did not include a diagnosis: Combigan 0.2/0.5% Solution. 2. The following medications on Resident #4?s MAR did not include a diagnosis: Calcium 600-10 tablet, Letrozole 2.5mg tablet, Levothyroxin 50mcg tablet, Memantine HCL 10mg tablet, Sertraline 50mg tablet, Theratears .25% Solution, and Melatonin 3mg tablet. 3. The following medications on Resident #5?s MAR did not include a diagnosis: Atorvastatin 40mg tablet, Cephalexin 250mg capsule, Glucos/chond 500-400 capsule, Irbesartan 75mg tablet, Levothyroxin 50mcg tablet, Multivitamin tablet, Omeprazole 40mg capsule, and Vitamin B-12 500mcg tablet. 4. The following medications on Resident #6?s MAR did not include a diagnosis: Vitamin B-12, Acetaminophen 650mg ER tablet, Caltrate+D 600-800 tablet, Cyanocobalam 1000mcg Solution, Levothyroxin 50mcg tablet, and Metoprol Suc 100mg ER tablet. 5. The following medications on Resident #7?s MAR did not include a diagnosis: Artificial Tears Solution and Preservision AREDs capsules. 6. The following medications on Resident #8?s MAR did not include a diagnosis: Multivitamin tablet, Magnesium Citrate 400mg tablet, Polyeth Glyc Powder 17gm, Preservision AREDs capsules, and Tolterodine 4mg ER capsule.
Plan of Correction:	Audit conducted on all current resident Mar's by Nurse Coordinator on 9/16/2022. Nurse Coordinator to ensure all resident MAR's include diagnosis for prescribed medications on admission.
Standard #:	22VAC40-73-720-A
Description:	Based on record review and interview, 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 admitting Physical Examination (dated 04/25/2022) indicates the code status of the resident as a full code. Additionally, Resident #2?s Face Sheet, ISP (dated 06/16/2022), Resident Binder, and signed Physician Order Sheet (dated 09/01/2022) indicate the resident as a DNR. Staff were unable to provide evidence of a signed DNR order or Durable DNR for Resident #2. 2. Upon review of Resident #3?s record, the signed Physician Order Sheet (dated 09/06/2022), ISP (dated 08/22/2022), and admitting Physical Examination (dated 08/10/2022) indicate the resident as a Full Code. However, the resident?s binder and Face Sheet indicate the resident as a DNR. The resident?s record also included a form titled ?Resident Emergency Code Status? to indicate the resident as a DNR with a physician signature dated 09/21/2022 (inspection held 09/13/2022 and 09/14/2022). 3. Upon review of Resident #5?s record, the binder for the resident, ISP (dated 09/06/2022), and admitting Physical Examination (dated 07/19/2022) indicate the code status of the resident as a DNR. However, the signed Physician Order Sheet (dated 09/01/2022) indicates the resident as a full code. 4. Upon review of Resident #6?s record, the binder for the resident, ISP (dated 07/25/2022), admitting Physical Examination (dated 06/09/2022), signed Physician Order Sheet (dated 09/01/2022) and Resident Face Sheet indicate the resident as a DNR. However, staff were unable to provide evidence of a signed DNR order or Durable DNR for Resident #6. 5. Upon review of Resident #7?s record, the binder for the resident and ISP (dated 05/23/2022) indicate the resident as a DNR. However, staff were unable to provide evidence of a signed DNR order or Durable DNR for Resident #7. 6. Upon review of Resident #8?s record, the ISP (dated 07/30/2022), signed Physician Order Sheet (dated 09/06/2022), and admitting Physical Examination (dated 07/26/2022) indicate the resident as a DNR. However, the binder of the resident indicates the resident as a Full Code. 7. Staff #1, Staff #2, and Staff #3 acknowledged the inconsistencies of the aforementioned resident?s code status and their records.
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. Chart Audits conducted by Divisional Nurse on all current residents on 9/15/2022. Resident Documents reviewed included: Bickford DNR Form Resident Face Sheet Physician Admitting Orders Resident ISP Resident POS Resident Service Plan Divisional Nurse conducted training with nurse care coordinator and assistant care coordinator on 9/16/2022 on proper procedure for ensuring resident code status is honored and proper documentation for resident charts.
Standard #:	22VAC40-73-960-B
Description:	Based on observation, the facility failed to ensure a fire and emergency evacuation drawing be posted in a conspicuous place on each floor of each building used by residents to include the location of the areas of refuge, assembly areas, fire alarm boxes, and telephones. Evidence: 1. During a tour of the facility on 09/13/2022, the emergency exit plans posted on the hallways did not include the areas of refuge, assembly areas, fire alarm boxes, or telephones.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. The following staff did not have a completed criminal history record report in their record: Staff #5 (hired 06/15/2022), Staff #6 (hired 06/27/2022), Staff #7 (hired 07/18/2022), Staff #8 (hired 07/11/2022), Staff #9 (hired 04/22/2022), Staff #10 (hired 04/13/2022), Staff #11 (hired 04/19/2022), Staff #12 (hired 06/06/2022), Staff #13 (hired 07/27/2022), Staff #14 (hired 06/06/2022).
Plan of Correction:	Once an offer of employment has been accepted, but prior to the start date Bickford will perform a background check through the Virginia Department of State Police utilizing the Non-Criminal Justice Interface. Print out the results and place in the BFMs personnel file. Results had not been returned by VDOSP for the following individuals. Reached out to department and they were able to provide a copy of results missing.