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: June 20, 2023 and July 17, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint On-site complaint inspection conducted on 6-20-23 (Ar 09:40 a.m./ dep 2:50 p.m.) 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 5-18-23 regarding allegations in the area of resident care and related services (medications) Number of residents present at the facility at the beginning of the inspection: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Number of staff records reviewed: Number of interviews conducted with residents: Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were 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 (Willie Barnes), Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on staff interviewed and documented reviewed, the facility failed to report the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health or safety of any resident. Evidence: 1. On 6-20-23 during a complaint inspection regarding residents not receiving medications, staff #1 presented the inspector with a list of residents whose medications needed to be re-ordered prior to the facility?s scheduled re-stocking date. 2. Staff #1 acknowledged not reporting the medication error per the facility Incident and Accident Report (PP-31000).
Plan of Correction:	*The incident involving the medications that needed to be reordered prior to the re-stocking date occurred on 4/30/23 - 5/2/23. This incident should have been formally reported to DSS no later than 5/3/23. *Staff #1 presented the final documents and billing statement on 6/20/23 in conclusion of the above referenced incident. *The Health & Wellness Dir. was educated on the necessity to report to the Exec. Dir. any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident so that guidance can be given and timely reporting can take place. *In the absence of the Exec. Dir., the Health & Wellness Dir., the Health & Wellness Coord., and the Family Advocate (in that order) are authorized to make the initial notification of a reportable event to DSS/Licensing Specialist within 24 hours of the event with the Final Notification being sent within 7 days of the event. Each will be educated on this process. *When notification of a reportable event has been made to DSS, an Outlook reminder will be sent to those mentioned above on day 5 as a reminder that the final report is due no later than day 7. Person Responsible: Exec. Dir., Health & Wellness Dir., Health & Wellness Coord., and Family Advocate Target Completion Date: 07/28/2023 and Ongoing
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on staff interviewed and documented reviewed, the facility failed to ensure medication was administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. On 6-20-23 during a complaint inspection regarding residents in the facility not receiving medications, staff #1 provided the inspector with a list with the names of residents who did not receive medications on April 30, 2023, May 1, 2023 and May 2, 2023. 2. A list of the medications for residents? who did not receive medications as prescribed was also provided. 3. There were forty-one (41) residents who did not receive medications a variety of medications as prescribed because the medications were not available in the facility to be administered. According to staff #2, the facility pharmacy had to be contacted to request it send medications to cover the days medications would not be available until the next re-supply date was scheduled. The medications for the April 30th day thru May 2 were with the April-May scheduled days bubble packets (April 5 to May 4th) but was not able to be located to the residents on April 30, 2023. 4. Staff #1 and #2 acknowledged residents? medications were not available in the facility to administer. The facility contacted its pharmacy manager to have additional medications sent to the facility to cover the missing medications.
Plan of Correction:	*The missed doses of medications referenced in Violation Notices dated 5/15/23 and 5/20/23 were delivered by the pharmacy on 5/2/23, along with May 2023 Cycle Fill medications, and were billed to and paid for by the Bickford of Virginia Beach. *Any resident or residents found to be out of any medications are to be called into the pharmacy during routine business hours or called into the ?after hours? pharmacist on call immediately so that a refill can be called into the local backup pharmacy to be filled timely. Director on Call will be responsible for picking up the prescriptions from the local pharmacy and delivering them to the Branch. *If there are any missed doses by residents, the prescriber will be notified by the Health & Wellness Dir.or Coord. This will be documented. *The Exec. Dir. is also to be notified immediately of any resident/residents who are without medications so that assistance/guidance can be provided, as needed. This includes managing any additional notifications that may be required. Person Responsible:Exec. Dir., Health & Wellness Dir., Health & Wellness Coord., and Family Advocate Target Completion Date: 7/28/2023