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: July 17, 2023 and July 24, 2023

Complaint Related: Yes

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 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint An on-site complaint inspection conducted on 7-17-23 (Ar 10:45 a.m./ dep 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 6-26-23 regarding allegations in the resident care and related services (medication). Number of residents present at the facility at the beginning of the inspection: 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 staff records reviewed: Number of interviews conducted with residents: Number of interviews conducted with staff: 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 some, but not all of the allegations; area(s) of non-compliance with standard(s) or law 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 (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 7-17-23 during a complaint inspection regarding residents not receiving medication, staff #1 acknowledged there was a medication error for resident #1 on 6-24-23. The licensing department received the incident on Tuesday, June 27, 2023 at 12:17 a.m.
Plan of Correction:	The incident involving the single dose of medication not given by the Agency personnel to Resident #1 on 6/24/23 should have been formally reported to DSS no later than 6/25/23. *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/notification of the event with the Final Notification being submitted within 7 days. 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. Responsible Person: Exec. Dir., Health & Wellness Dir., Health & Wellness Coord., and Family Advocate Target Completion Date: 7/28/23 & Ongoing
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that medications shall be 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 7-17-23, during a complaint inspection regarding medication not being administered, resident #1?s June 2023 medication administration record noted resident?s #1?s antibiotic was not administered. The resident was prescribed an antibiotic for 10 days, and to be administered twice a day. The June 2023 MAR for the 6-24-23 scheduled dosage at 8 p.m. was noted as not given. 2. Staff #3 stated attempt was made to assist staff #4 in locating resident #1?s medication but was rebuffed by staff #4 and the resident did not receive the medication, because staff #4 was not able to locate the medication on the cart.
Plan of Correction:	The Agency who provided the Registered Medication Aide for the 3-11 shift on 6/24/23 was notified on 6/25/23 by our Health & Wellness Dir., via their public 5-star rating system, that she was not a good fit and gave her a 1 star. *Resident #1 Provider was notified on 6/26/23 of the single dose not given by the Agency staff member and the 4 doses refused by the resident to receive additional instructions. *Moving forward, our goal is to have a staff member/RMA administer medications verses Agency personnel. If this is unavoidable, it will be the responsibility of the Health & Wellness Dir. or Coord. to review the medication variance report at the end of that shift to assure that the Agency personnel administered all medications and documented appropriately. Person Responsible: Health & Wellness Dir. or Coord. Target Completion Date: 7/28/23 & Ongoing