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: Jan. 23, 2023

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

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/23/2023 from 12:10 pm to 2:00 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 01/04/2023 regarding allegations in the area(s) of: Part VI Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 64 Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 Additional Comments/Discussion: Inspection focused on submitted self-reported incident. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 #:	22VAC40-73-220-B
Description:	Based on discussion, the facility failed to ensure when private duty personnel who are not employees of a licensed home care organization provide direct care or companion services to residents in an assisted living facility, the requirements listed under subdivisions A 2 through A 6 of this section apply. In addition, before direct care or companion services are initiated, the facility should obtain the required items listed in the standard. Evidence: 1. During the inspection, private duty personnel were observed with Resident #1 and state they provide care and companion services with the resident. Private duty personnel are with Resident #1 Monday through Friday from 10:15 am to 2:30 pm and 4:30 pm to 7:30 pm. 2. At the time of the inspection, Staff #1 was unable to provide documentation for either of the two private duty personnel?s qualifications, an original criminal history record report issued by the Virginia Department of State Police for each private duty personnel, documentation regarding tuberculosis for each private duty personnel, and documentation of orientation and training to each private duty personnel regarding the facility's policies and procedures related to the duties of private duty personnel. Staff #1 also acknowledged the direct care or companion services provided by private duty personnel to meet identified needs are not reflected on Resident #1's individualized service plan.
Plan of Correction:	Background Check's Complete
Standard #:	22VAC40-73-300-B
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. At the time of the inspection, Staff #1 was unable to provide a method of written communication 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 from 12/24/2022-12/29/2022.
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
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 progress notes in Resident #1?s record, Resident #1 fell on 08/05/2022, 08/06/2022, and 08/10/2022; however, at the time of the inspection, there is no documentation of a fall risk rating being completed after each fall in the resident?s record.
Plan of Correction:	Divisional Nurse conducted training on proper procedure for resident records reflect current status and care needs.
Standard #:	22VAC40-73-440-A
Description:	Based on record review and interview, the facility failed to complete a resident?s UAI whenever there is a significant change in a resident?s condition. Evidence: 1. Resident #1 returned to the facility on hospice on 01/11/2023; however, the most current UAI in the record of Resident #1 was completed on 07/02/2022. 2. Staff #1 acknowledged this was the most current UAI in Resident #1?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-C
Description:	Based on record review and interview, the facility failed to ensure the comprehensive ISP include a description of current identified needs and written description of what services will be provided to address identified needs. Evidence: 1. Resident #1 experienced a significant change upon readmission on 01/11/2023. Resident #1?s ISP dated 01/09/2023 does not reflect changes in the resident?s needs. The ISP indicates the resident has a ?Regular or No Added Salt Diet;? however, Resident #1?s record indicates their diet changed to pureed on 01/12/2023. The ISP indicates Resident #1 does not have a catheter; however, the record reflects the resident returned to the facility with a catheter in place. Staff #1 and Collateral #1 acknowledged and confirmed a catheter is in place and has been since readmission. Resident #1 has a history of falls and is rated a high fall risk per 12/20/22 fall risk rating; however, their ISP does not address the fall risk rating. 2. Staff #1 acknowledged the aforementioned needs were not accurately addressed on Resident #1?s current ISP.
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-D
Description:	Based on record review and interview, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan. Evidence: 1. Resident #1 readmitted to the facility on 01/11/2023 on hospice services; however, Resident #1?s ISP dated 01/09/2023 only indicates that Resident #1 requires health care coordination and ?requires coordinated health care with outside specialty services (such as P/T; O/T; hospice).? 2. Staff #1 acknowledged the ISP does not include the specific services provided by the facility and the licensed hospice organization.
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-E
Description:	Based on record review, the facility failed to ensure the individualized service plan be signed and dated by the licensee, administrator, or their designee, (i.e., the person who has developed the plan), and by the resident or their legal representative. Evidence: 1. Resident #1?s ISP dated 01/09/2023 is not signed and dated by the licensee, administrator, or their designee, (i.e., the person who has developed the plan), nor by the resident or their legal representative.
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 and or licensee. Administrator to conduct monthly audit to ensure all new residents have a current UAI.
Standard #:	22VAC40-73-460-F
Description:	Based on record review, the facility failed to document notification of the next of kin, legal representative, designated contact person, or, if applicable, any responsible social agency of any incident of a resident falling or wandering from the premises, whether or not it results in injury. This notification shall occur as soon as possible but no later than 24 hours from the time of initial discovery or knowledge of the incident. The resident's record shall include documentation of the notification, including date, time, caller, and person or agency notified. Evidence: 1. The shift notes on 12/20/22 indicate Resident #1 ?fell out of wheelchair.? Resident #1?s record does not include information regarding the fall and does not document notification to Resident #1?s next of kin, legal representative, or designated contact person. 2. Staff #1 acknowledges the record of Resident #1 does not reflect notification of fall to the responsible party.
Plan of Correction:	Family was notified per incident report. Re-education to team to ensure proper documentation is listed in resident chart following any occurrence.
Standard #:	22VAC40-73-470-F
Description:	Based on record review and interview, the facility failed to ensure when a resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional be secured immediately. The resident's physician, if not already involved, next of kin, legal representative, designated contact person, case manager, and any responsible social agency, as appropriate, shall be notified as soon as possible but no later than 24 hours from the situation and action taken, or if applicable, the resident's refusal of medical attention. Evidence: 1. Resident #1 fell on 12/20/2022. The record for Resident #1 does not indicate the resident?s condition following the fall nor circumstances in relation to the fall. The resident was sent to the ER on 01/03/2023 due to ?not responding well to commands? as documented in Resident #1?s progress notes. Resident was then admitted to the hospital for a closed displaced fracture of the left femoral neck. 2. Resident #1?s record and the shift notes provided during the inspection do not indicate the resident?s physician was notified of the resident?s change in condition. Shift notes indicate Resident #1 had complaints of leg pain on 12/30/2022, 12/31/2022, and 01/01/2023. The shift notes also indicated weakness of Resident #1 on 12/31/2022 and 01/01/2023. On 01/02/2023, staff note Resident #1 needed assistance with feeding. 3. At the time of the inspection, Staff #1 was unable to provide documentation that Resident #1?s physician was notified after the initial fall on 12/20/2022 nor the days following (12/21/2022-01/03/2023) as their condition changed.
Plan of Correction:	Incidents reports sent to Inspector. 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 #:	22VAC40-73-700-2
Description:	Based on observation, the facility failed to post "No Smoking-Oxygen in Use" signs and enforce the smoking prohibition in any room of a building where oxygen is in use. Evidence: 1. Resident #1 utilizes oxygen; however, there is not a ?No Smoking-Oxygen in Use? sign posted outside their apartment.
Plan of Correction:	Signage posted