VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bickford of Virginia Beach
2629 Princess Anne Road
Virginia beach, VA 23456
(757) 821-0198

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: Sept. 8, 2022 , Oct. 4, 2022 , Oct. 27, 2022 , Nov. 4, 2022 and Nov. 18, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS

Comments:

Type of inspection: Complaint An on-site complaint inspection was conducted on 9-8-22 (Ar 9:30/dep 14:00), 10-4-22 (Ar 9:55/ dep 18:00) and 10-27-22 (Ar 9:13/ dep 17:40). The facility census was 65 on 9-8-22. Staff and resident interviews were conducted. 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 8-25-22 regarding allegations in the area of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 65 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: 6 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 6 Observations by licensing inspector: yes Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes @dss.virginia.gov

Violations:

Standard #:	22VAC40-73-310-H
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals in the assisted living with any conditions or care need prohibited by the regulation and Code of Virginia for one of four records reviewed. Evidence: 1. On 9-8-22, resident #1?s medication administration record for September 2022 documented resident is prescribed Celexa. The record did not have documentation of a psychotropic treatment plan. 2. Staff acknowledged catheter care not completed.
Plan of Correction:	*Resident #1 provider will be contacted and a Psychoactive Treatment Plan obtained for the Celexa. *A list of Psychoactive Medications will be used to audit against all resident Physician Order Sheets to identify any other prescribed Psychoactive Medications to assure that each has the required Treatment Plan in the medical record or thinned chart. *The Psychoactive Treatment Plan order forms were added to the Provider?s binders who make visits in the Branch to see their patients. For those residents with Community Based Providers, the Psychoactive Treatment Plan order forms will be added to the envelope of information that residents take to their medical appointments. *The NCC, ACC, Dir., CRD or designee assisting a DSS Licensing Inspector will be reminded to also check a resident?s thinned record if a requested form cannot be found in the medical record. *Compliance with this requirement will be monitored during the routine weekly medication audits conducted by Nursing and during Nursing Core-Check audits. Person Responsible NCC/ACC and Dir.
Standard #:	22VAC40-73-320-B
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a risk assessment was completed annually for tuberculosis (TB) as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it for two of four records reviewed. Evidence: 1. On 9-8-22, the TB screening in resident #1?s and #2?s record was dated 5-26-21. 2. Staff #1 acknowledged the residents? TB were not updated.
Plan of Correction:	*Resident?s #1 & #2 had their annual TB screenings completed using the VA Dept. of Health screening form or one consistent with it on 11/18/22 *All resident records were audited to assure that those requiring an annual TB screening have one on file. *A binder will be utilized, with tabs by month, to both organize and track which residents have their annual TB screenings due each month. *The NCC/ACC will ensure that they are completed monthly by the Provider prior to their due date. *The NCC, ACC, Dir., CRD or designee assisting a DSS Licensing Inspector will be reminded to also check a resident?s thinned record if a requested form cannot be found in the medical record. *Compliance with this requirement will be monitored by the Dir. monthly and during scheduled Nursing Core-Check audits. 11/28/22 and ongoing Person Responsible: NCC/ACC/DIR or Designess
Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a fall rating was completed after a resident?s fall for one of four records reviewed. Evidence: 1. 0n 9-8-22, resident #3?s progress notes documented on 8-10-22 (07:30) resident was found on floor, resident refused to go to ER; abrasion noted on right cheek (ice applied); contusion on chin, and contusion to right fingers. The record did not include documentation of a risk rating. 2. Staff acknowledged the record did not include a risk rating following the resident?s fall.
Plan of Correction:	*Resident #3 had a Fall Risk Investigation Tool completed to assure that there is a current rating in her file. *Any existing residents who?ve had a fall since their Admission, Annual, or Significant Change Assessment will also have a Fall Risk Investigation Tool completed to assure that there is a current risk rating in their medical record. *NCC/ACC/Designee to be educated on the requirements of this form to include what triggers the need for a new fall risk assessment. *Post fall documentation will include a completed Fall Risk Investigation Tool to be reviewed, signed by the Director/Designee, and placed in the resident?s medical record. *The NCC, ACC, Dir., CRD or Designee assisting a DSS Licensing Inspector will be reminded to also check a resident?s thinned record if a requested form cannot be found in the medical record. * Compliance with this requirement will be monitored by the Dir. monthly and during scheduled Nursing Core-Check audits. 12/31/22 and ongoing Person Responsible: NCC/ACC/DIR/Or Designee
Standard #:	22VAC40-73-390-A
Complaint related:	Yes
Description:	Based on documents provided and policy provided, the facility failed to ensure when there was an increase in charges, the resident/legal representative would be provided advanced notice of intent to increase charges for four of four records reviewed. Evidence: 1. On 9-8-22, in response to a complaint allegation of services being bill and notification not provided, a request of residents? bills and notification information was requested. 2. A billing statement was provided for residents #1, #2, #3 and #4. The request for notification was not provided. 3. On 10-04-22, the request for documentation of notification of rate increases to residents was to the staff #1. Staff #1 was not able to provide documentation of rate increase notices to residents and/or legal representative. 4. On 11-4-22, a copy of the facility?s was received noted in Section IV.B (Rent, Fees and Deposits) noted, thirty (30) day written notice is not required if there is a change in the level of care charges pursuant to the Resident Service Assessment and Rate matrix. A change in level of care charges pursuant to the Resident Service Agreement and Rate Matrix will become effective upon notice to the Resident or Resident?s Representative. The record did not have documentation of changes in the residents? service agreement since admission, the initial agreement upon admit to the facility. The record did not include any amendments to the initial agreement. 5. The facility?s Change in Level of Care (VA)-PP-60450 policy noted 1.f- the Resident Admission Agreement will be updated as appropriate. The document also not 1.e- a resident had the right to appeal the outcome of the assessment, reassessment, or determination of level of care. 6. Resident #1?s Individual Service Plan (ISP) was signed and dated by the representative 12-14-21. The Resident Agreement in the record is dated 12-3-19. Resident #2?s ISP is signed and dated 1-12-22, the resident agreement is dated 12-23-19. Resident #3?s ISP is noted as 180-day assessment (7-20-22), there is not facility staff signature or date and not resident or representative signature. The resident agreement is signed and dated 6-11-20. Resident #4?s 180-day assessment (6-30-22), no signature by facility staff and no resident/representative signature. The Resident agreement is signed and dated 12-5-19. 7. Staff #1 acknowledged on 10-4-22 and 10-27-22, the record does not include documentation of rate increase notices to the resident and/or representative. Staff #1 stated the increase is provided during assessment review with the resident/family. The reviews in the record are not signed and dated by the resident/or representative.
Plan of Correction:	*Residents #1, #2, #3, & #4 have a copy of the most current annual increase letter in their file. *Residents #1 & #2 financial POA has participated in email/text/verbal/in person conversations about the charges of #1 & #2, which are also clearly displayed, by resident per day, on the monthly invoices mailed to the financial POA monthly. The Director will arrange to have additional explanation provided so that all charges can be comprehended and understood by the financial POA. That documentation will be maintained in the resident?s Admin. file. *All current resident?s Admin. files will contain a copy of all annual rate increase letters mailed to the address of record for each resident. Those residents who receive a change in their level of care charges will have the revised Service Plan emailed to the address of record, as an attachment, with the change in fees included in the body of the email. A copy of that email will be filed in the resident?s Admin. file. *Resident Admin. files will be audited for compliance during schedule Core-Check audits. 12/19/22 and ongoing Person Responsible: DIR/ADMIN ASST/ or Designee
Standard #:	22VAC40-73-450-C
Complaint related:	Yes
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for four of four records reviewed. Evidence: 1. On 9-8-22 resident #1?s individualized service plan (ISP) dated 12-14-21 (end date 6/2022) did not include the resident?s Speech therapy services. The record included services for cognition/short-term memory/problem solving concerns dated 12-8-21 to 1-5-22. Physical therapy services not included on the ISP; service dates: 1-2-22 to 3-17-22 and 3-18-22 to 5-21-22. The uniformed assessment instrument (UAI) dated 12-14-21 assessed wheeling and stairclimbing as not performed; these areas were not included on the ISP. Bathing need assessed on UAI as mechanical help/supervision; the ISP did not include supervision. 2. Resident #2?s ISP dated 1-12-22 and 5-24-22 did not include the resident?s Speech therapy (2-2-22 to 6-7-22 and 6-8-22 to 9-5-22), Occupational Therapy (1-31-22 to 4-30-22, 5-1-22 to 7-29-22 and 7-30-22 to 9-27-22) and Physical Therapy (1-19-21 to 4-18-22, 4-19-22 to 7-17-22 and 7-18-22 to 9-30-22). The resident?s pacemaker noted on the resident?s physical dated 12-13-19 was not documented on the ISP. 3. Resident #3?s uniformed assessment instrument (UAI) dated 7-20-22, mobility assessed as mechanical help/physical assistance, this need was not on the ISP dated 7-20-22. 4. Resident #4?s ISP dated 11-29-21 and 6-30-22 did not include the resident?s Physical therapy services (2-11-22 to 5-27-22). 5. Staff acknowledged the ISPs for the aforementioned residents did not include all assessed needs.
Plan of Correction:	*Resident #1 Service Plan to be updated to reflect most current Speech & Physical Therapy treatment plans summary, visit schedule, goals, and achievement dates once reached. The most current ISP/UAI will be reviewed to assure that identified care needs and abilities match on both documents. *Resident #2 Service Plan to be updated to reflect the most current Speech & Occupational Therapy treatment plans summary, visit schedule, goals and achievement dates once reached. The pacemaker, referenced on the Physical form, will be added to the Service Plan and noted on the UAI. *Resident #3 most current ISP/UAI will be reviewed to assure that identified care needs and abilities match on both documents to include mobility. *Resident #4 Service Plan to be updated to reflect the most current Physical Therapy treatment plans summary, visit schedule, goals and achievement dates once reached. 12/19/22 and ongoing Person Responsible: NCC/ACC/DIR/ or Designee
Standard #:	22VAC40-73-460-H
Complaint related:	Yes
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure that personal assistance and care was provided to a resident so that needs of the resident was met. Evidence: 1. On 9-8-22 during a complaint allegation regarding resident #1?s catheter care, the record documented on 8-17-22 during the healthcare provider?s visit, the healthcare?s notes documented the following concern: there was a lot of pus around SPT site. It was very red and irritated. Needs to be cleaned and kept dry. New orders to empty catheter bag when it is half full- Do not let it get any fuller- make sure catheter is anchored to patient and not hanging?. Make sure SPT site stays clean and dry. The individual service plan (ISP) dated 14-14-21 documented staff to provide catheter care: empty bag three times a day on each shift, provide catheter care provided by BFM Care staff/problems to be reported to RNC/ACC by care staff and skin integrity to remain intact. 2. On 10-27-22- Staff?s training record reviewed did not document when staff members received catheter training. 3. On 10-27-22, staff #1 was not able to determine when facility staff members were provided training on catheter care.
Plan of Correction:	catheter care and drainage bag maintenance profiled on QuickMar so that the RMAs will be prompted to complete those tasks as ordered. *Nursing BFMs, responsible for catheter care, to receive documented training demonstrating competency with catheter care. *NCC/ACC responsible to assure that the staff working with those residents with special needs have the training required to meet their care needs. This training will be documented. 12/19/22 and ongoing Person Responsible: NCC/ACC or Designee
Standard #:	22VAC40-73-610-A
Complaint related:	Yes
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it honored the food preferences of one of four resident. Evidence: 1. On 9-8-22, a food preference allegation was conducted. Resident #1?s food preference as noted in the resident?s record documented resident being a picky eater and preferences for hamburgers, pizza, hotdogs and Italian foods. This preference is also noted on the resident?s ISP. The facility ?Bread Basket-Scratch Kitchen? menu included items of preference that resident #1 preferred to choose meals. On 9-8-22, a copy of the alternate menu was provided to the inspectors. According to staff #3, the alternate menu was no longer being served, but the staff would prepare the grilled cheese sandwich for resident #1. The resident wanted other items from the alternate menu such as the Bread Basket Burger but could not have items. Staff was asked if the residents were informed that the alternate menu was no longer being served, staff #3 stated residents were not informed of the change. 2. Staff #3 acknowledged the resident?s preference was not honored due to the menu items not being served as noted when the resident was first admitted on 12-23-19.
Plan of Correction:	Staff #3 to meet with resident #1 to assure that his meal preferences are updated and properly documented on the Meal Notification form. *Staff #3 to implement the ?Daily Fare? menu, 1 item per week, until all Bickford options are available. Those menus will be posted, as planned, and any substitutes or deletions will be posted and communicated to the residents. *Menu preferences will continue to be open for discussion at the monthly Resident Council Meetings, conducted by the LEC. Staff #3 will be invited to participate in those meetings when needed. *The utilization of the ?Daily Fare? menus will be monitored during daily rounds. 12/31/22 and ongoing Person Responsible: KM/CRD/LEC/DIR/ or Designee
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the medication administration record (MAR) included all required information for one of four records reviewed. Evidence: 1. On 9-8-22, resident #2?s June and July 2022?s medication administration record (MAR) did not include the diagnosis, condition, or specific indications for administering the following drug or supplement: Calcium Carbonate, Carvedilol, Digoxin, Donepezil, Eliquis, Entresto, Furosemide, Levetiracetam, L-Lysine, Loperamide, Oxcarbazepine, Restasis, Sertraline, Spironolactone, Thera-M, Vitamin D and C. 2. Staff acknowledged the MAR did not include the diagnosis for the prescribed drugs and supplements.
Plan of Correction:	*Resident #2 Physician Order Sheets were audited to assure that all current medications have a diagnosis, condition, or specific indications for taking each medication. *All resident Physician Order Sheets were audited to assure that all current medications have a diagnosis, condition, or specific indications for taking each medication. *All admission orders and new orders will be reviewed prior to profiling to assure that they include all required information prior to being submitted to the pharmacy to be profiled. Once those orders are profiled, the NCC/ACC will review and approve in QuickMar to assure that all orders were entered correctly and contain the correct information. *This will be audited weekly by the NCC/ACC during scheduled medication audits and by the 10th of each month by the Director 12/19/22 and onging Person Responsible: NCC/ACC/DIR/Divisional Nurse/ or Designee
Standard #:	22VAC40-73-710-C
Complaint related:	No
Description:	Based on observation and staff interviewed, the facility failed to ensure when a restraint is used, the requirements for usage was completed. Evidence: 1. On 9-8-22, a U-bar was observed attached to resident #2?s bed. The record did not have documentation for the use of a U-bar. There was no documentation on the individualized service plan and no physician?s order specifying the condition, circumstances, and duration under which the restraint was to be used. 2. On 10-27-22, staff #1 acknowledged the record did not contain documentation for resident #1?s U-bar and there was no written physician?s order for this restraint.
Plan of Correction:	*Resident #2 therapy providers, Fox Rehab, have been contacted regarding the U-Bar to determine if it is still needed or if it can be removed. That information will be shared with the Provider and then updated on the UAI and Service Plan. *All resident apartments will be inspected to assure that there are no adaptive devices attached to the bed without an appropriate assessment and Provider orders for that device. *All residents/POA/Responsible Parties will be reminded/notified about the ?bedrail policy? that is signed at the time of admission and asked to not provide any adaptive equipment that must be attached to the bed prior to contacting Nursing or the Director in advance. *Nursing/Housekeeping/ Maintenance will be re-educated on the Branch policy regarding siderails and other adaptive equipment that falls into that category and asked to report any such devices observed in any resident apartments. *Home Health/Hospice/Rehab providers will also be re-educated on the need to consult with Nursing or the Director prior to attaching any adaptive equipment to a resident?s bed. *Compliance with this will be monitored during routine rounds of resident apartments by Nursing/Housekeeping/ Maintenance/Branch Directors 12/19/22 and ongoing Person Responsible: NCC/ACC/DIR/or Designee