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 15, 2023 , May 16, 2023 , June 20, 2023 and July 17, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS

Comments:

Type of inspection: Complaint A joint complaint inspection with APS was conducted on 5-15-23. The Inspector visited facility also on 5-16-23. 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 5-9-23 regarding allegations in the resident care and related services (medication). Number of residents present at the facility at the beginning of the inspection: 59 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: Number of interviews conducted with residents: Number of interviews conducted with staff: 4 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 allegations 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 willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-B
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure an annual risk assessment for tuberculosis (TB) was completed for a resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. On 5-16-23, during a complaint inspection, resident #3?s TB screening in the record was dated 10-24-21. 2. Staff #2 was not able to locate a recent screening for the aforementioned resident.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-D
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure uniform assessment instrument for private pay individual was completed as required. Evidence: 1. On 5-15-23, resident #1?s UAI dated 5-4-23 was not signed and dated by another facility staff, when the assessor who completed the form was identified as a facility staff member. 2. On 5-16-23, resident #2?s UAI dated 1-10-23 was not signed by another facility staff member when the assessor who completed the form was identified as a facility staff member.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure comprehensive individualized service plan (ISP) included all assessed needs. Evidence: 1. On 5-16-23, resident #2?s uniform assessment instrument (UAI) dated 1-10-23 documented wheeling and stairclimbing need assessed as mechanical help (mh). The ISP dated 1-10-23 did not include these assessed needs. The resident?s record included documentation of psychiatric services, 2-7-23 and 3-7-23 for psychotropic medications. This service was not documented on the ISP.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator or his designee, and by the resident or his legal representative. Evidence: 1. On 5-15-23 during a joint complaint inspection, resident #1?s ISP dated 5-4-23 was not signed by the resident and/or the resident?s representative.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all updated and/or significant changes. Evidence: 1. On 5-15-23, resident #1?s uniform assessment instrument (UAI) dated 5-4-23 documented toileting as mechanical help/human help/physical assistance. The ISP documented resident toilets with reminders, use of handrails to transfer. Stairclimbing assessed as mechanical help/ human help/physical assistance. The ISP documented use of handrails. The record included a physician?s order dated 2-13-23 for resident?s food to be cut up due to dysphagia. This assessed need was not on the UAI and not on the ISP. 2. Resident #3?s UAI dated 11-21-22 documented bathing assessed as mechanical help. The ISP dated 5-21-22 documented physical assistance by staff to wash lower extremities. Mobility assessed as mechanical help. The ISP did not include this assessed need. 3. On 5-16-23, resident #4?s UAI dated 3-10-23 documented transferring need as mechanical help. Stairclimbing assessed as mechanical help. The ISP documented mechanical help/ physical assistance; however, the mechanical device was not identified. The ISP dated 3-10-23 did not include this assessed need. The was observed using Oxygen. A check of the resident physician?s order documented resident?s use of oxygen (2 LPM via NC continuous). Resident also receives psychiatric services which was not on the ISP.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure medications 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 5-15-23 during a joint complaint inspection allegation of resident #1 being admitted to the hospital due to not receiving medications, the interview with staff #1 and #2 confirmed resident did not receive medications. Documentation in the resident?s record noted resident was admitted to a local hospital on 5-2-23 and discharged on 5-5-23. The resident?s record noted resident did not receive the following medications on 4-30-23: (a) Arthritis pain, (b) Coreg, (c) Entresto, (d) Keppra and (e) Trileptal. The following were noted as not administered on 5-1-23 (a) Arthritis pain, (b) Coreg, (c) Digoxin, (d) Eliquis, (e) Entresto, (f) Lasix, (g) Keppra, (h) Loperamide, (i) Multivitamin, (j) Trileptal, (k) Zoloft, (l) Aldactone and (m) Vitamin D. Interview with staff stated the medications were not available to administer. Further interview revealed the medications were not available because it may have been thrown away. According to staff #2 the facility medications for the cycle is received on the 3rd or 4th of the month; residents medication for the 30th day of the current month and 1st, 2nd and 3rd day of the next month is included in the current month blister pack. 2. During the joint interview, it was stated by staff #1 and #2 that there were several residents who did not receive medication. The staff did not give a specific number. Residents #2, #4, #5 and #6?s medication administration record (MAR) for April 2023 and May 2023 were reviewed for medication not being administered. Resident #4 and #5?s record noted medication not being administered, awaiting pharmacy delivery. 3. Staff #1 and #2 acknowledged there were residents? who did not receive their medications because it was not in the facility to administer. According to staff #1, the medication was reordered from the facility?s out of -state pharmacy as ?replacement medications?.
Plan of Correction:	The provider/licensee did not provide a plan of correction by the due date.