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: Nov. 30, 2022 , Dec. 13, 2022 , Dec. 5, 2022 , Dec. 19, 2022 , Dec. 27, 2022 and Dec. 29, 2022

Complaint Related: No

Areas Reviewed:

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 An unannounced renewal inspection was conducted on 11-30-22 (ar 07:35 a.m./dep 20:00 p.m.) The census on day one was 60. A tour of the facility was conducted, medication pass observed, staff and resident interviews and records reviewed, emergency preparedness reviewed, `breakfast meal observed. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-40-A
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure it complied with its policy regarding criminal record check. Evidence: 1. On 11-30-22, the facility staff listing of new employees noted staff #7?s date of hire as 8-21-22. Staff #7?s criminal record check (CRC) received on 12-5-22 was dated 8-31-22. 2. On 12-27-22, following the facility?s third preliminary exit, staff #1 provided the inspector with staff #7?s timesheet noting first day of work as 8-30-22 and date of hire as 8-21-22. 3. The facility?s policy document staff?s criminal record check to be received prior to beginning work.
Plan of Correction:	*Staff #7 start date was 8/30/22. The negative criminal history report was received on 8/31/22, and her sworn disclosure with no pending or conviction data was received on 8/24/22. Although regulations allow 30 days to receive the results, Bickford?s policy is to obtain the results prior to starting. *Moving forward, staff will not be permitted to start orientation ?on-site? until the background check is complete. *All active staff records will be audited, and properly notated, to identify any other records containing a background check received after the ?on-site? start date. *Any new hires with a ?pending? background check result from the VA State Police will be told that they cannot start until the report is received in the mail and approved. Person Responsible: Exec. Dir. or Designee Target Completion Date: 12/27/22 & Ongoing
Standard #:	22VAC40-73-380-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s personal and social information placed in resident?s record was kept current. Evidence: 1. On 11-30-22, resident #1?s social data was not updated to include resident?s allergies. The allergy section was blank. The resident?s uniform assessment instrument (UAI) dated 5-2-22 and 7-11-22 noted in the comment section resident?s allergy to Sulfa antibiotic and statin drug allergies.
Plan of Correction:	* Resident #1 had the allergies updated on the Social Data Form/Face Sheet. *All resident Social Data/Face Sheets will be reviewed to assure that the allergy section is completed, as appropriate. *At the time of move in, the Admin. Assist will review all Social Data/Face Sheets and will have the resident/POA provide any missing information. *A final review will be completed by the Dir./Designee to assure that there is no missing information on the Social Data/Face Sheet. Person Responsible: Admin. Assist/Exec. Dir. or Designee Target Date of Completion: 1/25/23 Ongoing
Standard #:	22VAC40-73-450-C
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 six residents. Evidence: 1. On 11-30-22, resident #1?s uniformed assessment instrument (UAI) dated 5-2-22 and 7-11-22 documented stairclimbing needs assessed as mechanical help/physical assistance. The resident?s ISP dated 7-11-22 did not include this assessed need. 2. Resident #2?s UAI dated 7-5-22 and 8-10-22 documented transferring as mechanical help, wheeling and stairclimbing as not performed. The ISP dated 7-8-22 did not include these assessed needs. 3. Resident #4?s UAI dated 3-23-21 and 6-15-22 documented wheeling as not performed and stairclimbing as mechanical help/physical assistance. These assessed needs were not on the ISP dated 6-15-22 (received from staff #2 on 12-13-22). 4. Resident #6?s UAI dated 9-21-21 and 3-16-22 documented dressing, toileting and transferring as mechanical help/physical assistance. The ISP dated 6-8-22 did not include the mechanical assistance for dressing, toileting and transferring. Stairclimbing documented as not performed, this assessed need was not documented on the ISP. The record included documentation of speech therapy services (10-5-22, 10-25-22 and 8-27-22). This service was not documented on the ISP.
Plan of Correction:	*Residents #1 current Service Plan will be updated to reflect the current stair climbing needs. Resident #2 current Service Plan will be updated to reflect the current transferring, stair climbing, and wheeling needs. Resident #4 current Service Plan will be updated to reflect the current stair climbing needs, & Resident #6 current Service Plan will be updated to reflect the current dressing, toileting, transferring, and stair climbing needs. *All resident Service Plans are in the process of being reviewed and updated, per our policy, and the needs identified on the UAI will be audited against the Service Plan by the BFM who completed it to assure that all needs are accurately reflected on the Service Plan. *The UAIs and Service Plans will be audited a second time by the Dir., or designee, at the time of signature, to assure that all identified needs on the UAI are reflected on the Service Plan. Person Responsible: HWC/Exec.Dir/ or Designee Target Date: 1/25/23 & Ongoing
Standard #:	22VAC40-73-450-E
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the license, administrator, or designee (i.e., the person who had developed the plan), and by the resident or resident?s legal representative. The plan should indicate any other individuals who contributed to the development of the plan, with a notation of the date of contribution. The title or relationship to the resident of each person involved in the development of the plan. These requirements shall also apply to reviews and updates of the plan. Evidence: 1. On 11-30-22, resident #1?s individualized service plan (ISP) signed and dated by facility staff representative on 7-11-22 did not include the signature and date of the resident and/or legal representative. 2. On 11-30-22, resident #2?s ISP dated 7-8-22 was not signed and dated by the facility, the resident/or legal representative. 3. On 12-13-22, resident #4?s ISP dated 6-15-22 was not signed and dated by the facility, the resident and/or legal representative.
Plan of Correction:	*Residents #1, #2, & #4 Service Plans will be reviewed and signed by those designated to sign. *All current Service Plans in the medical records will be checked to assure that each contain the required signatures. When the Service Plans are pending Resident/POA signature, a copy of the email accompanying the Service Plan will be attached to that Service Plan in the chart and tracked for completion by the Admin. Asst. *Ongoing monitoring will take place during routine Nursing Core Checks. Person Responsible: HWC/Exec. Dir./ Admin. Asst. or Designee Target Date: 1/25/23 & Ongoing
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition for two of six records reviewed. Evidence: 1. On 11-30-22 resident #1?s record documented resident began receiving hospice services on 7-18-22. The record also documented resident was receiving physical therapy and occupational therapy services, start of services dated 5-26-22. The record documented physical therapy services were discontinued on 7-18-22 and occupational therapy services discontinued on 8-18-22. The ISP was not signed and dated by the facility, resident and/or legal representative to include this review and change in resident?s services (outcome achieved and or discontinued services). 2. On 11-30-22, resident #2?s record documented occupational therapy services were discontinued on 10-11-22. The ISP was not updated and reviewed to document this change in services.
Plan of Correction:	*Resident #1 & #2 current Services Plans will be updated to reflect any additional services received by vendors. *Current caseload information will be obtained by any vendors providing services to the residents to assure that all are updated on the current Service Plan and Special Needs List *The Special Needs List will be used to audit Service Plans to assure that the current services are reflected are reflected on the Service Plans. Person Responsible: HWC/Dir./ or Designee Target Date: 1/25/23 & Ongoing
Standard #:	22VAC40-73-640-A
Description:	Based on observation and staff interviewed, the facility failed to ensure it implemented it medication management plan for proper disposal of medication. Evidence: 1. On 11-30-22 during the medication observation pass with staff #5, the staff went to a container with multiple medications to check for a PRN medication for resident #5. 2. When inquired why the observed medications were being collected in this box. Staff stated the container contained medications that were discontinued. 3. A count of the medication packages and containers determined that there were fifty packets/containers of medications for sixteen residents. The medication dates range from March 2022 to October 2022 and included medications of various categories, over-the counter medications, psychotropic medications, controlled substances, hospice medications. 4. The facility medication management policy PP-61050 for VA, disposal instructions on page 6 was not conducted by facility staff. Controlled medications which need to be dispose were not kept under double lock, medications that could be returned to pharmacy were not returned. The facility policy regarding destruction of medications were not conducted in a timely manner as plan stated.
Plan of Correction:	*The Health and Wellness Director immediately removed all identified medications from the secured medication room and properly disposed of them, per Bickford policy, on 12/1/22 *Moving forward, all discontinued medications or those prescribed for residents who have been discharged, will be properly disposed of within 7-14 days. *This process will be monitored during weekly Medication Cart Audits conducted by the HWC. Person Responsible: HWD or Designee Target Date: 12/27/2022 & Ongoing
Standard #:	22VAC40-73-650-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the physician?s order, both written and oral identified the diagnosis, condition or specific conditions for administering for each drug. Evidence: 1. On 11-30-22, during the medication pass observation with staff #4, resident #2?s November 2022 medication administration record (MAR) and physician?s order dated 10-1-22 did not include diagnosis for the following: Acetaminophen, Diclofenac, Fluticasone, Gabapentin, Lidocaine, Neuriva Plus, Probiotic, Restasis, Benefiber powder, Ibuprofen, Loperamide, Meclizine and Ondansetron. 2. On 11-30-22, during the medication pass observation with staff #5, resident #6?s November 2022 MAR and physician?s order dated 11-21-22 did not include diagnosis for Timolol. 3. On 11-30-22 staff #4 and #5 acknowledged the resident?s medication did not include diagnosis.
Plan of Correction:	*Residents #2 & #6 had their Physician Order Sheets & MARs updated to include a diagnosis for each medication prescribed. *All resident Physician Order Sheets & MARs for Jan. 2023 will be audited by the Health and Wellness Director to identify any that are missing diagnosis and have them clarified and then corrected. *The Physician Order Sheets and MARs will be audited during scheduled Nursing Core Checks to assure that all required information is listed. Person Responsible: HWD/Dir. or Designee Target Date of Completion: 1/25/23 & Ongoing
Standard #:	22VAC40-73-680-I
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the medication administration record (MAR) included all required information. Evidence: 1. On 11-30-22 during medication pass observation with staff #4, resident #1?s November 2022 medication administration record (MAR) did not include a diagnosis, condition, or specific indications for Bumetanide and Potassium Chloride.
Plan of Correction:	*Resident #1 will have their Physician Order Sheet and MAR updated to include the diagnosis, condition, or specific indications for Bumetanide and Potassium Chloride. *All resident Physician Order Sheets & MARs for Jan. 2023 will be audited by the Health and Wellness Director to identify any that are missing the diagnosis, condition, or specific indications; have them clarified; and then corrected. *The Physician Order Sheets and MARs will be audited during scheduled Nursing Core Checks to assure that all required information is listed. Person Responsible: HWD/Dir. or Designee Target Date of Completion: 1/25/23 & Ongoing
Standard #:	22VAC40-73-680-M
Description:	Based on observation and staff interviewed, the facility failed to ensure medications ordered for PRN administration was available, properly labeled for the specific resident, and properly stored at the facility. Evidence: 1. On 11-30-22 during medication pass observation with staff #5, resident #3?s PRN Tylenol was not available in the facility. 2. Resident #5?s PRN Lotrisone, Loperamide and Vaseline not available in the facility. 3. Resident #6?s PRN Senna Plus and Citrucel not available in the facility.
Plan of Correction:	*Residents #3, #5, & #6 had their identified PRN medications re-ordered to assure that they are on site and available to give if needed. *All residents with PRN medication orders will be audited by the Health and Wellness Director to assure that all prescribed PRN medications are on site and available to give, if needed. *All Medication Aides will be re-educated on the need to request refills from the pharmacy for any resident who needs their PRN medications refilled and will immediately report to the HWC any challenges with that process. *This will be monitored during weekly Medication Audits. Person Responsible: HWD or Designee Target Date of Completion: 1/13/2023 and Ongoing