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: Oct. 4, 2022 , Oct. 27, 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

Comments:

Type of inspection: Complaint Complaint inspection conducted on 10-4-22 (Ar 9:55/dep 18:00) and 10-27-22 (ar 9:13/dep 17:40 p.m). 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 9-27-22 regarding allegations in the area of resident care. Number of residents present at the facility at the beginning of the inspection: 64 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 staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 6 Observations by licensing inspector: bed rails, mattress, no oxygen sign on door where Oxygen concentrator located in room with resident with O2 Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 #:	22VAC40-73-440-H
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure an annual reassessment and reassessment due to a significant change in the resident?s condition, using the uniform assessment instrument (UAI) was utilized to determine whether a resident?s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: 1. On 10-4-22, during a complaint inspection, resident #1?s record did not include an updated or annual reassessment using the UAI. The UAI?s in the record were dated 9-23-20, 10-24-20 and 8-27-21. The resident?s initial date of admission was documented as 10-2-20. The resident was sent out to the emergency room following a fall on 6-30-22 where diagnoses was a broken hip. The resident went to rehabilitation and returned to the facility on 8-2-22. The resident returned with noticeable weight loss and decline. Hospice services was assessed and started 9-22-22. 2. There was no UAI to include resident?s change in condition and or annual assessment which was also due.
Plan of Correction:	*Resident #1 was discharged while under Hospice care on 11/1/22. *NCC/ACC/Designee will be re-educated on the situations which trigger a new assessment and the need to revise the UAI and implement a new Service Plan. *All current resident medical records will be audited to assure that the most current updated/revised resident UAI and Service Plan, reflecting any current significant changes, is in the medical record. *The NCC/ACC/DIR/CRD, or Designee, assisting the DSS Licensing Inspector during an inspection, 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 scheduled Nursing Core-Check audits. Person Responsible: NCC/ACC/DIR/Designee
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on observation, record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs. Evidence: 1. On 10-4-22, resident #1?s record documented resident?s wound care services, pressure ulcer to left hip, stage 2. Start of care noted 4-20-22; heel pressure ulcer dated 8-31-22 (right heel ? 2 x 3 cm and left heel 3x 3 cm). prescriber?s order for wound care evaluate and treat (necrotic area noted left heel (9-2-22). The hospice nurse?s notation dated 9-22-22 noted a stage 1 on the coccyx area. These services were not documented on the resident?s ISP in the record on 10-4-22. The resident?s ISP noted resident is a high fall risk. A mat was observed on floor (window side) next to the resident?s bed on 10-4-22. 2. Resident?s record also contained prescriber?s order for PT/OT (physical therapy/occupational therapy) 12/12/21 and 11/23/21. The record did not include documentation of resident receiving therapy services.
Plan of Correction:	*Resident #1 was discharged while under Hospice care on 11/1/22. *All current resident medical records will be audited, using the current ?Special Needs? list, to assure that the Service Plan reflects the most current conditions, care needs, and any provider services addressing those needs. *The NCC/ACC/DIR/CRD, or Designee, assisting the DSS Licensing Inspector during an inspection, 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 scheduled Nursing Core-Check audits. Person Responsible: NCC/ACC/DIR/Designee
Standard #:	22VAC40-73-450-D
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated pan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP). Evidence: 1. On 10-4-22, resident #1?s record documented receiving Skilled nursing services, social worker, chaplain, dietician, and an aide. The ISP dated 9-6-22 did not include these services from the hospice agency. 2. On 10-4-22 and 10-27-22, staff acknowledged the hospice services were not documented on resident #1?s ISP.
Plan of Correction:	*Resident #1 was discharged while under Hospice care on 11/1/22. *NCC/ACC/Designee will be re-educated on the situations which trigger a new assessment and the need to revise the UAI and implement a new Service Plan that reflects all services being provided to that resident. *All current resident medical records will be audited, using the current ?Special Needs? list, to assure that the Service Plan reflects the most current conditions, care needs, and any provider services addressing those needs. *Compliance with this requirement will be monitored during scheduled Nursing Core-Check audits. Person Responsible: NCC/ACC/DIR/Designee
Standard #:	22VAC40-73-700-2
Complaint related:	No
Description:	Based on observation and record review, the facility failed to ensure it posted ?No-Smoking-Oxygen in Use? sign in any room of a building where oxygen is in use. Evidence: 1. On 10-4-22, there was not a ?No -Smoking-Oxygen-in Use? sign posted on resident #1?s door. The record documented resident prescribed, 2 lpm via nasal cannula, concentrator- prescriber?s order dated 9-22-22. 2. On 10-4-22 staff acknowledged the required no-smoking sign was not posted for room #306.
Plan of Correction:	*Resident #1 had a ?No Smoking ? Oxygen in Use? sign placed on the entrance door on to the apartment on 10/4/22 to alert those entering the apartment that Oxygen was in use. *The Admin. Assist. Made several laminated ?No Smoking ? Oxygen in use? signs to be hung on any apartment door where Oxygen is in use. Those are located in the main office and at both nurses? stations *When a new order for Oxygen is received and then delivered by the O2 vendor, the Admin. Asst. or Designated in Charge will ensure that the appropriate signage in hung on that residents apartment door. *Compliance with this requirement will be monitored during scheduled Nursing Core-Check audits. 10/7/22 and ongoing Person Responsible: Admin. Asst./Designated in Charge/NCC/ ACC/DIR
Standard #:	22VAC40-73-710-C
Complaint related:	No
Description:	Based on observation and staff interviewed, the facility failed to ensure if a restraint is used, it must be imposed in accordance with a physician?s written order that specifies the condition, circumstances, and duration under which the restraint is to be used. Evidence: 1. On 10-4-22, a black cloth, non-traditional bed rail was observed on the right side (window side) of resident #1?s bed. When resident was asked what the rail was used for, the resident was not able to state the use of the bed rail. 2. Staff acknowledged there was a bed rail in resident #1?s room and attached to the bed, no physician?s order noted in record.
Plan of Correction:	*Resident #1 POA/son was informed on 9-30-22 that side rails of any kind were not permitted, per the signed acknowledged at the time of move in. Trinity Hospice provided a hospital bed without siderails, on 9-30-22. On 10-5-22, the family was notified that the device they placed on the hospital bed after it was delivered needed to be removed, per policy, and that Trinity Hospice would be lowering the bed and providing fall mats for both sides of the bed. *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 to the NCC/ACC/DIR. *Home Health/Hospice/Rehab providers will also be re-educated on the need to consult with NCC/ACC/DIR 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. Person Responsible: NCC/ACC/DIR/Designee