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 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Complaint An unannounced complaint inspection was conducted on-site on 10-4-22 (ar 9:55/dep 6:00) and 10-27-22 (ar 9:13/dep 5:40) 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 9-29-22 regarding allegations in the resident care/abuse. Number of residents present at the facility at the beginning of the inspection: 63 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: special care unit Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the resident care/abuse 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 #:	22VAC40-73-1110-B
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure an annual review of the appropriateness of each resident?s continued residence in the special care unit was conducted. Evidence: 1. On 10-4-22, the last assessment for placement in the special care unit for resident #1 was dated 5-26-21. The resident?s date of admission to the special care unit was dated 11-29-19, also the date of admission to the facility. 2. On 10-27-22, staff #1 acknowledged the record did not have an update special care unit assessment.
Plan of Correction:	*Resident #1 has a Review of Appropriate Placement in the medical record dated 5/26/22 *All Memory Care medical records were audited to assure that each contained a current ?Review of Appropriate Placement? if indicated. *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 Nursing Core-Check audits. Person Responsible: NCC/ACC or 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 ISP dated 9-7-22 did not include resident?s allergy to Penicillin, information noted in resident?s 9-4-22 visit to the emergency room. The nursing assessment dated 9-7-22 documented the resident is hard of hearing, this information was not on the ISP. Resident?s uniform assessment instrument (UAI) dated 9-7-22 assessed transferring need as mechanical help/the ISP noted transfer with verbal cue but did not document a mechanical device. Eating need assessed as no help/ the ISP documented resident sometimes require staff to feed resident during meals. 2. Staff acknowledged the ISP did not include all required information.
Plan of Correction:	*Resident #1 admission History and Physical form, dated 10/18/19, has ?Sulfa Antibiotics? listed under allergies by her Provider. The Provider for Resident #1 was contacted for clarification regarding the discrepancy with the drug allergy list provided by them and Sentara Princess Anne Hospital. That clarification was provided on 12/7/22 and shared with the pharmacy for inclusion on the MAR/Physician Order Sheet. This clarification will be maintained in the resident?s medical file. *Resident #1 ISP will be updated to include hearing loss. *Resident #1?s current ability to complete transfers will be updated on the current UAI and Service Plan. *Resident #1 current need for assistance with eating will be evaluated and then updated on the current UAI and Service Plan, as indicated. *Following each UAI and ISP update, both will be audited against each other to assure that they match. Any discrepancies will be clarified and corrected on both documents * Compliance with this requirement will be monitored during Nursing Core-Check audits. Person Responsible: NCC/ACC/DIR or Designee
Standard #:	22VAC40-73-470-A
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it either directly or indirectly, the health care services need of a resident was met. Evidence: 1. On 10-4-22 resident #2?s record included a prescriber?s order dated 7-29-22 for Speech therapy, secondary to cough with eating and to rule out dysphagia. The did not include documentation of service being evaluated. 2. On 10-27-22, staff acknowledged the record did not include documentation of the speech therapy status.
Plan of Correction:	*Resident #2 Speech Therapy orders, dated 7-29-22, were referred to CenterWell Home Health for eval. and treat. Per CenterWell, resident #2 Husband did not sign and return consent forms. After multiple attempts, they rejected the referral. *Resident #2 Provider to be consulted regarding current need for SP eval. This will be documented in the medical file. *NCC/ACC to be educated on the need to assure that all orders are carried out, or when appropriate, discontinued by the Provider. *NCC/ACC to be educated on steps to follow when POA consent cannot be obtained. *Two step double check process to be followed with all new vendor orders to assure that all have been carried out, properly documented, and added to the Service Plan as indicated. * Compliance with this requirement will be monitored during Nursing Core-Check audits. Person Responsible: NCC/ACC or Designee