VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bickford of Suffolk
6860 Harbour View Boulevard
Suffolk, VA 23435
(757) 215-0058

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Feb. 14, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/14/2023 from 10:00 am to 11:30 am. 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 02/02/2023 regarding allegations in the area(s) of: Part II Administration and Administrative Services, Part V Admission, Retention and Discharge of Residents, and Part VI Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 42 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 interviews conducted with staff: 7 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Part II Administration and Administrative Services and Part VI Resident Care and Related Services. A violation notice was 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-150-C
Complaint related:	Yes
Description:	Based on interviews and record review, the administrator failed to demonstrate responsibility for the general administration and management of the facility and overseeing the day-to-day operation of the facility which includes ensuring staff and volunteers comply with residents' rights. Evidence: 1. Through interviews with floor staff, Staff #1, and Staff #2, it was determined SafelyYou video of fall events was utilized for training purposes during an all-staff meeting. 2. The SafelyYou policy for video use and documentation indicates SafelyYou services for consented residents will be accessible to authorized users which may include members of the Leadership Team. 3. The Resident Consent to Fall Detection Program for those that opt into SafelyYou services does not include consent authorizing the video documentation for general staff training.
Plan of Correction:	The insufficiency will be corrected as follows: Director/Health & Wellness Director will go over resident?s rights during all Staff In-Service on March 2nd, 2023. Director will ensure only direct care staff will view future SafelyYou video effective 2/14/2023. The following measures will be taken to ensure problems do not occur again: 2/14/2023 Only direct care staff has access to view SafelyYou videos. Persons responsible to implement and monitor corrective measure to ensure compliance: Director/Health & Wellness Director.
Standard #:	22VAC40-73-560-F
Complaint related:	Yes
Description:	Based on interview, the facility failed to ensure all records are treated confidentially and that information shall be made available only when needed for care of the resident. Evidence: 1. The facility utilizes the SafelyYou video monitoring system to identify resident health or safety risk, including fall detection and intervention for residents with cognitive impairment upon obtaining responsible party consent. The SafelyYou policy for video use and documentation indicates ?SafelyYou video of Fall Events is considered part of the Resident?s Medical Record.? 2. The utilization of residents? medical record via SafelyYou video footage was not treated confidentially when shared as part of a general all-staff training. 3. Interviews with floor staff, Staff #1, and Staff #2 confirmed SafelyYou video of fall events was utilized for training purposes during an all-staff meeting.
Plan of Correction:	The insufficiency will be corrected as follows: Director will ensure any resident SafelyYou video will be viewed privately. Effective 2/14/2023. The following measures will be taken to ensure problems do not occur again: 2/14/2023 Only direct care staff has access to view SafelyYou videos confidentially. Persons responsible to implement and monitor corrective measure to ensure compliance: Director/ Health & Wellness Director.
Standard #:	22VAC40-73-680-B
Complaint related:	No
Description:	Based on observation, the facility failed to ensure medications include the prescription label or direction label attached. Evidence: 1. On 2/9/2023, the facility received a verbal order to change Resident #1?s Sertraline order from 100 mg to 150 mg. The MAR was updated to reflect this change; however, the medication on the cart (Sertraline 100 mg tablet) reads ?take 1 tablet by mouth daily.? 2. Staff #3 acknowledged the label on the Sertraline for Resident #1 does not reflect the current order.
Plan of Correction:	The insufficiency will be corrected as follows: Health & Wellness Director corrected the medication label on 2/14/2023. The following measures will be taken to ensure problems do not occur again: Persons responsible to implement and monitor corrective measure to ensure compliance: Health & Wellness Director will ensure med cart audits are done on a weekly basis to ensure medication labels matches the MAR. Effective 2/14/23. Persons responsible to implement and monitor corrective measure to ensure compliance: Health & Wellness Director.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. Resident #1?s record indicates the dosage of the resident?s Sertraline order changed from 150 mg to 100 mg on 01/14/2023; however, the MAR for Resident #1 documents the resident was administered 150 mg of Sertraline from 01/14/2023 to 02/02/2023. The MAR was adjusted on 02/02/2023 to the correct 100 mg dosage. 2. Staff #1 and Staff #2 acknowledged the MAR does not reflect the resident?s Sertraline order dosage change from 150 mg to 100 mg from 01/14/2023 to 02/02/2023, and indicates the resident received 150 mg of Sertraline during that time.
Plan of Correction:	The insufficiency will be corrected as follows: Health & Wellness Director corrected the MAR to match the physicians order on 2/2/2023. The following measures will be taken to ensure problems do not occur again: Health & Wellness Director will ensure med cart audits are done on a weekly basis to ensure medication labels matches the MAR. Effective 2/14/23. Persons responsible to implement and monitor corrective measure to ensure compliance: Health & Wellness Director.