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: May 1, 2023 , May 15, 2023 and July 17, 2023

Complaint Related: No

Areas Reviewed:

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: Monitoring An on-site monitoring inspection following IPOC was conducted on 5-1-23 (Ar 09:38 a / Dep 4:05 p). The facility census was 61. The administrator was not present but arrived later. Resident?s records were reviewed and a medication pass was conducted. The inspections repeat violations facility IPOC plan reviewed with administrator and staff. 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 #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for two of three resident?s record. Evidence: 1. On 5-1-23, resident #1?s uniform assessment instrument (UAI) dated 3-16-23 documented dressing (AM/PM care) need as mechanical help/human help/supervision (mh/hh/s). The individualized service plan (ISP) dated 3-17-23 documented resident required staff cueing and physical assistance/ standby assist to complete task. There was no documentation of what mechanical help was needed. Bathing need assessed as mh/s. The ISP documented staff to wash missing areas and hard to reach areas and step by step cueing. Toileting assessed as mechanical help (mh). The ISP documented resident is independent. Walking, stairclimbing, wheeling and mobility assessed as mechanical help (mh). The ISP documented mobility/escorts, resident self-propel wheelchair. The ISP did not include walking and stairclimbing. Physical therapy, occupational therapy and speech therapy documented on ISP; however, services start date, what services and when services were provided was not documented on the ISP. Resident?s date of admit noted as 3-17-23. 2. Resident #2?s UAI dated 3-30-23 not bathing needs assessed as mechanical help/human help/supervision (mh/hh/s). The individualized service plan dated 4-4-23 documented resident needed physical assistance for bathing.
Plan of Correction:	*Residents #1 will have the Service Plan (ISP) updated to include what current type of mechanical help is needed with dressing and toileting, what physical help is needed with bathing at this time, how stair climbing and walking are currently performed, and PT/OT/SP start dates/needed services/frequency if indicated. *Resident #2 will have the Service Plan (ISP) updated for bathing to include what type of mechanical help is currently needed and whether supervision or physical help is needed at this time. *Bickford of Virginia Beach is transitioning to August Health, an electronic documentation system which will capture needs identified on the electronic UAI assessment and accurately transfer them to the Service Plan (ISP). From there, each identified need will be individualized. At this time, all residents are having new UAI assessments and Service Plans completed in August Health as a part of the implementation of this new system. *All Assessments and Service Plans will be reviewed\approved by the Exec. Dir./Designee as required and can also be monitored virtually by Divisional Leadership. Person Responsible: Health & Wellness Director & Coordinator/ Designee and the Exec. Dir, Target Completion Date: 8/10/23 and 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 one of three records reviewed. Evidence: 1. Resident #3?s UAI dated 1-8-23 documented dressing as mechanical help/human help/physical assistance. The ISP dated 1-8-23 did not document what mechanical help was needed. Bladder was not documented as an assessed need on the UAI. The ISP documented family provides incontinent products. The skilled nursing and occupational therapy services documents also noted resident was incontinent of bladder. Stairclimbing, walking and mobility assessed as mechanical help (mh). The ISP did not document stairclimbing need; mobility documented resident able to walk short distances, resident required mechanical help and physical assistance. Mobility documented resident walk short distances/ physical and mechanical help needed. Resident?s record included physician?s orders dated 1-5-23 for Physical therapy, Occupational Therapy and Speech Therapy, this was not documented on the ISP. The record included therapy service notes certified 2-23 to 4-23-23. The record also included occupational therapy discharge service date 3-9-23. The ISP did not include this change. A physician?s order dated 2-17-23 for PT/OT and Una boot for bilateral lower extremity (BLE) was in the record. These services were not documented on the resident?s ISP. The resident?s date of admit was noted as 6-11-20.
Plan of Correction:	* Resident #3 will have the UAI assessment and Service Plan (ISP) updated to include what current type of mechanical help is needed with dressing, what current type of bladder care is needed (to include the provision of supplies), what the current stairclimbing/walking/ mobility mechanical/physical assistance needs are, and the current PT/OT/SP start dates/needed services/adaptive equipment (Una Boot)/frequency if indicated. *Bickford of Virginia Beach is transitioning to August Health, an electronic documentation system which will capture needs identified on the electronic UAI assessment and accurately transfer them to the Service Plan (ISP). From there, each identified need will be individualized. At this time, all residents are having new UAI assessments and Service Plans completed in August Health as a part of the implementation of this new system. *All Assessments and Service Plans will be reviewed\approved by the Exec. Dir./Designee as required and can also be monitored virtually by Divisional Leadership. Person Responsible: Health & Wellness Director & Coordinator/ Designee and the Exec. Dir Target Completion Date: 8/10/23 and Ongoing
Standard #:	22VAC40-73-640-A
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 one of three records reviewed. Evidence: 1. Resident #3?s UAI dated 1-8-23 documented dressing as mechanical help/human help/physical assistance. The ISP dated 1-8-23 did not document what mechanical help was needed. Bladder was not documented as an assessed need on the UAI. The ISP documented family provides incontinent products. The skilled nursing and occupational therapy services documents also noted resident was incontinent of bladder. Stairclimbing, walking and mobility assessed as mechanical help (mh). The ISP did not document stairclimbing need; mobility documented resident able to walk short distances, resident required mechanical help and physical assistance. Mobility documented resident walk short distances/ physical and mechanical help needed. Resident?s record included physician?s orders dated 1-5-23 for Physical therapy, Occupational Therapy and Speech Therapy, this was not documented on the ISP. The record included therapy service notes certified 2-23 to 4-23-23. The record also included occupational therapy discharge service date 3-9-23. The ISP did not include this change. A physician?s order dated 2-17-23 for PT/OT and Una boot for bilateral lower extremity (BLE) was in the record. These services were not documented on the resident?s ISP. The resident?s date of admit was noted as 6-11-20.
Plan of Correction:	*The Health & Wellness Dir. reviewed all of the medications for Resident #1 and assured that all were on hand. *The Health & Wellness Dir. and Coord. reviewed all other resident medications provided by their families to assure that all were on hand. *Those Families/Responsible Parties will be emailed regarding their responsibility with regards to assuring that our resident has all ordered medications on hand to give at all times. *If a Family/Responsible Party fails to provide a medication/refill on time, the resident?s Provider will be asked to call in a refill to our local backup pharmacy, and a conversation will be had with that Family/Responsible Party regarding their responsibility and the potential of switching to our commercial pharmacy for reliability purposes. *This will be monitored weekly by the Health & Wellness Dir. and Coord. during the weekly Medication Variance Audits Person Responsible: Health & Wellness Dir. and Coord./Designee Target Date of Completion: 8/1/23
Standard #:	22VAC40-73-680-C
Description:	Based on observation, record reviewed and staff interviewed, the facility failed to ensure medications shall be administered not earlier than one hour before and not later than one hour after the facility?s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: 1. On 5-1-23, during the medication pass observation with staff #3, the inspector inquired and was informed that there were three other residents who needed to receive medications. The time on the facility?s medication screen was 10:53 a.m. 2. Resident #4 did not receive the prescribed mediation according to the scheduled dosing time. The following medications were scheduled for 9:00 a.m.: (a) Arthritis pain, (b) Artificial Tears, (c) Coreg, (d) Digoxin, (e) Eliquis, (f) Entresto, (g) Lasix, (h) Keppra, (i) Imodium, (j) Multivitamin, (k) Trileptal, (l) Restasis, (m) Zoloft, (n) Aldactone and (o) Vitamin D. 3. Resident #5 did not receive the prescribed medication according to the scheduled dosing time. The following medications were scheduled for 8:00 a.m.: (a) Vitamin B-12 injection, and (b) Pepcid. The following medications were scheduled for 9:00 a.m.: (a) Synthroid, (b) Multivitamin, (c) Sanctura XR, (d) Valsartan and (e) Vitamin D3. Ensure was scheduled at 10:00 a.m. 4. Resident #6 did not receive the prescribed medication according to the scheduled dosing time. The following medications were scheduled for 9:00 a.m.: (a) Albuterol nebulizer, (b) Uroxatral, (c) Lipitor, (d) Aero inhaler, (e) Alphagan, (f) Eliquis, (g) Fenofibrate, (h) Hydrazaline, (i) Irbesartan, (j) Singular, (k) Procardia, (l) Vitamin B-12 and (m) Vitamin D2.
Plan of Correction:	*The Providers for Residents #3, #4, #5, & #6 were notified that their patients received their medications late on 5/1/23. There were no new orders. *Bickford of Virginia Beach has received a second med cart to be used for Assisted Living, due to the quantity of medications ordered. Assignments and med pass times will be evaluated and adjusted to allow for the additional time/manpower needed to pass all prescribed medications within the allowed timeframe. *This will be monitored weekly by the Health & Wellness Dir. & Coord. during the Weekly Medication Variance Audits. Person Responsible: Health & Wellness Dir. and Coord. Target Date of Completion: 8/4/23 and Ongoing