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: Oct. 27, 2022

Complaint Related: Yes

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

Technical Assistance:

22VAC40-73-540. Visitation in the facility. 22VAC40-73-990. Plan for resident emergencies and practice exercise.

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/27/2022 from 9:00 am to 2:25 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/24/2022 and 10/25/2022 regarding allegations in the area(s) of: Part III Personnel, Part IV Staffing and Supervision, Part VI Resident Care and Related Services, Part VIII Building and Grounds, Part IX Emergency Preparedness, and Part X Additional Requirements for Facilities that care for adults with serious cognitive impairments. Number of residents present at the facility at the beginning of the inspection: 52 (including 13 residents in the safe, secure environment) The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 4 Additional Comments/Discussion: Inspection was specific to the safe, secure environment. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Part III Personnel, Part IV Staffing and Supervision, Part VI Resident Care and Related Services, and Part X Additional Requirements for Facilities that care for adults with serious cognitive impairments. A violation notice was issued; any violation(s) not related to the complaints 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
Complaint related:	No
Description:	Based on record review, the facility failed to ensure prior to admission to a safe, secure environment, residents have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. Resident #1 did not have documentation of an assessment from an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Plan of Correction:	Original documentation for Resident #1 was provided to family at an earlier date. Family request for medical records will need to be requested and emailed to provide electronic copy. Original documents will be maintained in resident's chart. A Copy of Resident # 1 documentation of initial assessment was obtained from physician on 11/1/22.
Standard #:	22VAC40-73-1110-A
Complaint related:	No
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 #4 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 #:	22VAC40-73-1120-F
Complaint related:	Yes
Description:	Based on discussion, the facility failed to ensure the designated, qualified staff person responsible for managing or coordinating the structured activities program is on site in the special care unit at least 20 hours a week. Evidence: 1. During a tour of the facility, nursing staff were observed conducting activities within the safe, secure environment. 2. Staff #6 acknowledged the designated, qualified staff person responsible for managing or coordinating the structured activities program is not on site in the special care unit at least 20 hours a week.
Plan of Correction:	Restructure occurred to ensure qualified staff person responsible for managing structured activities in special care unit is present in memory care 20 hours a week.
Standard #:	22VAC40-73-1130-A
Complaint related:	Yes
Description:	Based on observation and interview, the facility failed to ensure except during night hours, when 20 or fewer residents are present, at least two direct care staff members shall be awake and on duty at all times in each special care unit who shall be responsible for the care and supervision of the residents. Evidence: 1. During the inspection held on 10/27/2022, Staff #8 relieved Staff #5 for their break; however, Staff #8 is not direct care staff. This resulted in Staff #3 being the only direct care staff during Staff #5?s break off the unit.
Plan of Correction:	Education with Staff to ensure proper members of the care team are relieving during break time. This will help ensure direct care staff is in place to care for residents.
Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on record review, the facility failed to ensure any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident to the regional licensing office within 24 hours. Evidence: 1. During a review of the Communication Log on 10/19/2022, it indicates Resident #5 was ?sent to the hospital per family request due to fractured hip xray.? The assigned licensing inspector has not received notification of the incident prior to, at the time of or after completion of onsite inspection.
Plan of Correction:	Administrator will notify DSS Inspector of resident incidents within 24 hours of incident.
Standard #:	22VAC40-73-250-D
Complaint related:	No
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 04/13/2022) was not dated. 1. There is no documentation of a completed initial tuberculosis risk assessment for Staff #2 (hire date 06/26/2022) or Staff #3 (hire date 10/04/2022).
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.
Standard #:	22VAC40-73-260-A
Complaint related:	No
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 #2 and Staff #4 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 12/8/2022 Audit to be conducted 1/mth on New Hire Staff Files.
Standard #:	22VAC40-73-300-B
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure a method of written communication be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. Evidence: 1. Resident #1 was observed within the safe, secure environment with both left and right hands bandaged. Upon review of Resident #1?s record, there is only documentation regarding fracture to the resident?s left hand following a fall on 10/16/2022. 2. Staff #7 stated the skin tears to the resident?s right hand were due to the resident being combative during care. Staff #7 acknowledged there was no written documentation in the communication book or resident record regarding this injury.
Plan of Correction:	Nurse Coordinator to conduct in-service regarding documentation- To include resident illnesses, complaints, incidents, behavior/mentation changes, something that you observe with the resident that you haven?t seen before). Occurrences will be documented on the resident?s Progress Notes and reported directly to the Nurse Coordinator and noted in the Communication Book. Nurse Coordinator will complete a 3 day follow up, following resident incident reports for the next 30 days to ensure proper procedures for documentation are completed.
Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on record review, the facility failed to ensure a fall risk rating is completed after a fall. Evidence: 1. Upon review of the resident?s record, Resident #1 fell on 10/16/2022; however, there is no documentation of a fall risk rating being completed after the fall in the resident?s record.
Plan of Correction:	Divisional Nurse conducted training with assistant nurse care coordinator on 11/1/22 on proper procedure for resident records reflect current status and care needs.
Standard #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on record review and interview, the facility failed to complete a resident?s UAI prior to admission. Evidence: 1. At the time of the inspection, Staff #7 could not produce a UAI for Resident #4 (admitted 10/05/2022), and one could not be found in the resident?s record.
Plan of Correction:	Nurse Coordinator to ensure All residents of assisted living facilities shall be assessed face to face using the uniform assessment instrument. The UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition. Administrator to conduct monthly audit to ensure all new residents have a current UAI.
Standard #:	22VAC40-73-450-A
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to develop a preliminary plan of care to address the basic needs of the resident that adequately protects his health, safety, and welfare on or within seven days prior to the day of admission. Evidence: 1. At the time of the inspection, Staff #7 could not produce an ISP for Resident #4 (admitted 10/05/2022), and one could not be found in the resident?s record.
Plan of Correction:	Nurse Coordinator to ensure All residents of assisted living facilities shall be assessed face to face and will develop a comprehensive ISP to meet the resident's service needs. ISP will be provided to family for review, signed and dated. Administrator to conduct monthly audit to ensure all new residents have a current UAI.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on record review, the facility failed to ensure individualized service plans be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. Resident #2 moved from the assisted living portion of the facility to the safe, secure environment on 10/11/2022; however, Resident #2?s ISP was not updated to reflect this significant change.
Plan of Correction:	Nurse Coordinator to ensure All residents of assisted living facilities shall be assessed face to face using the uniform assessment instrument. The UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition. Administrator to conduct monthly audit to ensure all new residents have a current UAI.
Standard #:	22VAC40-73-460-H
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met. Evidence: 1. Documentation for showers between 10/12/2022-10/27/2022 were reviewed via the Communication Book to ensure bathing is occurring at least twice a week, but more often if needed or desired. The following are the documented completion or attempts of bathing on the records reviewed: Resident #1 ? 10/12, 10/18, 10/21, 10/25, Resident #2 ? no documentation of completion or attempts, Resident #3 ? 10/12, and Resident #4 ? 10/18, 10/21. The documentation for Resident #2, Resident #3, and Resident #4 does not indicate the residents are receiving bathing at least twice a week.
Plan of Correction:	Documentation for resident showers are completed on Staff Assignment Sheets. Staff Assignment sheets for resident #1, #2, #3, #4 will be submitted to DSS Inspector. Staff #7 Educated on location of forms to ensure proper documentation is given to inspector.
Standard #:	22VAC40-73-520-I
Complaint related:	No
Description:	Based on observation and interview, 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. 2. Staff #6 acknowledged the current month activity schedule is not currently posted in the safe, secure environment.
Plan of Correction:	Weekly Calendars Posted Monthly Calendar posted on 10/27/22
Standard #:	22VAC40-73-610-B
Complaint related:	Yes
Description:	Based on observation and interview, the facility failed to ensure menu for meals for the current week are dated and posted in an area conspicuous to residents. Evidence: 1. During a tour of the facility, only the breakfast, lunch, and dinner menu for 10/27/2022 was available within the safe, secure environment. 2. Staff #7 acknowledged the menu for meals for the current week was not posted in an area conspicuous to residents in the safe, secure environment.
Plan of Correction:	Kitchen Manager will ensure posting of current menus in an area conspicuous to residents and families in Memory Care.
Standard #:	22VAC40-73-680-I
Complaint related:	No
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 #2?s MAR did not include a diagnosis: Atorvastatin 10mg tablet, Benefiber on Pow the Go, Famotidine 20mg tablet, Loperamide 2mg capsule, Melatonin 3mg tablet, Memantine 10mg HCL tablet, Multivitamin Adult 50+ tablet, Omeprazole 20mg capsule, Rivastigmine patch, Vitamin D3 25mcg tablet, Deep Sea Nasal Spray .65% solution, and Diclofenac gel 1%.
Plan of Correction:	Audit conducted on all current resident Mar's by Nurse Coordinator on 11/1/22. Nurse Coordinator to ensure all resident MAR's include diagnosis for prescribed medications on admission. Divisional Nurse to conduct Audit in 30 days to ensure all new residents MAR's include diagnosis.