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: Sept. 25, 2023 and Oct. 5, 2023

Complaint Related: No

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 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal An on-site renewal inspection was conducted on 9-25-23. Ar (07:55 a.m./Dep 18:30 p.m.) The facility census was 61. A tour of the facility was conducted, medication pass observed, dinner observed, staff and resident interviews and records reviewed, emergency preparedness reviewed. 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 #:	22VAC40-73-1110-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident?s continued residence in the special care unit. Evidence: 1. On 9-25-23, resident #1?s record did not have documentation of continued appropriateness of place and continued residence. The resident?s dated of admit noted as 3-15-23.
Plan of Correction:	*Resident #1 had the Documentation of Continued Appropriate Placement completed. This will be uploaded into August Health. *All other MBs residents will have their files audited to assure that no other documents are past due. *Those responsible for completing this document will receive an Outlook reminder on the 1st of the month that the next document is due. Upon completion, they will be uploaded into August Health. Person Responsible: Health & Wellness Dir. & Coord., Exec. Dir. Target Date of Completion: 10/16/23
Standard #:	22VAC40-73-1180-B
Description:	Based on observation and staff interviewed, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision. Evidence: 1. On 9-25-23 during a tour of the safe, secure unit with staff #10, a heavy steel iron was observed on unit in the ?Sewing is my therapy? activity section. 2. Staff #4 acknowledged the item was not appropriate for the residents on the unit.
Plan of Correction:	*This vintage iron was a part of one of our Life Stations and was removed at that time. *Because this can be very subjective, all items purchased or received as donations will be looked at closely by our management team for a collective decision on whether those items intended for the stimulation and enjoyment of our Mary Bs residents poses any obvious safety hazards. Person Responsible: Exec. Dir., Family Advocate, Health & Wellness Dir. and Coord. Target Date of Completion: 9/25/23
Standard #:	22VAC40-73-100-C-2
Description:	Based on observation and staff interviewed, the facility failed to ensure the facility?s infection control policy was implemented during the medication pass observation. Evidence: 1. On 9-25-23 during the medication pass observation with staff #3, resident #5?s blood sugar was checked. The staff was observed removing the glucometer from the container and placing it on top of the medication cart. Next the staff placed the glucometer on counter behind the medication cart next to the oscillating fan that was in use. The glucometer was not sanitized prior to the finger stick be conducted.
Plan of Correction:	*An in-service for the Registered Medication Aides was conducted by the Divisional Nurse on 10/10/23 and included Administration of Insulin, Medication Administration, and Designated Person In Charge Duties And Responsibilities. Documentation of such will be maintained in their personnel file/training record. *All newly hired RMAs, as a part of their initial orientation, will review Bickford?s policies on Administration of Insulin, Medication Administration, and Designated Person In Charge Duties And Responsibilities. Documentation of such will be maintained in their personnel file/training record. * All RMAs will review these policies annually during the 4 Hour Med Tech Refresher course, and documentation of such will be maintained in their personnel file/training record. *This requirement will be added to the personnel file audit tool, and compliance will be monitored during personnel file audits. . Person Responsible: Health & Wellness Dir., Coord., Divisional Nurse or Designee Target Completion Date: 10/10/23 Ongoin
Standard #:	22VAC40-73-70-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that it reported to the regional licensing office within 24 hours any major incident that has negatively affected the or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. On 9-30-23, staff #1 submitted to the licensing office, two incident reports for resident #9. The incidents noted falls and transporting to a local hospital due to resident acknowledging pain. These incidents occurred 9-21-23 and 9-23-23. 2. On 10-2-23, the licensing office received an incident report for resident #10. The incident noted resident was hospitalized with a diagnosis of Acute Respiratory Failure with Hypoxia due to COPD and Exacerbation and UTI. This incident occurred on 9-23-23.
Plan of Correction:	*Resident #9 had 2 complete incident reports submitted on 9/30/23. *Resident #10 incident report was finalized and submitted on 10/2/23 *Effective 10/5/23, any ?major incident? will now include any chronic or acute health conditions that result in a trip to the hospital emergency room. *All members of the Management Team, Registered Medication Aides, and those Designated in Charge will be educated on the requirement to report any event that has negatively affected or that threatens the life, health, safety or welfare of any resident to both the Executive Director and the Health & Wellness Director as soon as feasibly possible and no later than the end of their shift. *All Direct Care staff members to be re-educated on the importance of documenting those events in the resident?s electronic chart as soon as possible and no later than the end of their shift so that information needed for the DSS Incident Report is available to those responsible for submitting those reports. *This will be monitored/reviewed at the daily standup staff meetings. Person Responsible Exec. Dir., Health & Wellness Director, Family Advocate or Designee Target Completion Date 10/13/23 & Ongoing
Standard #:	22VAC40-73-120-B
Description:	Based on record review and staff interview, the facility failed to ensure the orientation training included all required information. Evidence: 1. On 9-25-23, the facility orientation document completed by staff #8 did not include purpose of the facility, daily routines, specific duties and responsibilities of the staff?s position and methods of alleviating common adjustments problems that may occur when a resident moves from one residential environment to another.
Plan of Correction:	*Staff member #8 to receive orientation training on the purpose of the facility, daily routines, specific duties and responsibilities of the staff member?s position, and methods of alleviating common adjustment problems that may occur when a resident moves from one residential environment to another. *All other active staff members will receive orientation training on the purpose of the facility, daily routines, specific duties and responsibilities of the staff member?s position, and methods of alleviating common adjustment problems that may occur when a resident moves from one residential environment to another. *Staff Orientation tools to be updated to reflect the inclusion of these topics. Person Responsible: Exec. Dir. or Designee
Standard #:	22VAC40-73-220-A
Description:	Based on record review and staff interviewed, the facility failed to ensure when private duty personnel from licensed home care organizations provide direct care or companion services to residents in an assisted living facility, the facility shall provide orientation and training to the private duty personnel. Evidence: 1. On 9-25-23, a private duty personnel was observed accompanying resident #5 to the medication room. CS-1 record did not include documentation on the type and frequency of services to be delivered to the resident by the private duty personnel. The facility failed to ensure that the requirements regarding tuberculosis (TB) were met; CS-1?s TB was dated 4-1-22. The facility did not have documentation of orientation and training to CS-1 regarding the facilities policies and procedures related to the private duty personnel?s duties. 2. Staff #1 acknowledged the required training, orientation and documentation for CS-1, private duty personnel for resident #5 was not completed.
Plan of Correction:	*CS-1 private duty file was updated to reflect documentation on the type and frequency of services to be delivered to the resident by the private duty personnel, obtained a current TB Screening, and provided orientation and training to CS-1 regarding the facilities policies and procedures related to the private duty personnel?s duties. *Audit any other CS private duty files to assure that they are current and updated, as needed. *Contacted the company who provides resident #5 private duty personnel and again provided them with a copy of DSS Standard 22VAC40-73-220-A regarding their responsibilities and our requirements regarding any private duty personnel working in our Branch. It was stressed that these requirements must be met prior to them beginning services. Also requested that they track and then initiate any changes to their schedule or services provided so that the residents Service Plan can be updated and track when the annual TB screening is due. We will also set up an Outlook reminder of that due date. *CS Private Duty files will be audited and updated at the time of that Outlook reminder. Person Responsible: Exec. Dir., Admin. Asst. or Designee Target Completion Date: 10/18/23 & Ongoing
Standard #:	22VAC40-73-260-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that each direct care staff maintained current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. On 9-25-23, staff #6?s record did not include current first aid within sixty days of hire. The staff?s date of hire was noted as 3-24-23 and first day of work noted as 4-5-23.
Plan of Correction:	*Bickford of Virginia Beach provides CPR & First Aid training to all staff members twice a year. Our most recent class was scheduled and conducted on 9/28/23. Staff #6 was on the list and did receive her recertification on 9/29/23. *A 100% audit of all personnel files was conducted to identify any Direct Care Staff who do not have current First Aid certification. *Proof of current First Aid certification is requested at the time of hire. For those who do not have current certification, it will be explained that they have 55 days from their start date to obtain the training and provide us with a copy of their card. On day 60, they will be removed from the schedule until the certification is received. Person Responsible: Exec. Dir., Admin. Asst. or Designee Target Completion Date: 10/18/23 & Ongoing
Standard #:	22VAC40-73-310-H
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure it did not admit retain individuals with a prohibitive conditions or care needs. Evidence: 1. On 9-25-23, resident #5?s record included an order dated 7-12-23 for Sertraline and Trazodone (start date 1-27-23). The record did not include a psychotropic treatment plan for these medications. 2. Resident #6?s physician order dated 7-7-23 for Haloperidol and Lorazepam (start date 6-9-23). Trazadone noted with a prescribed with a start date of 7-27-23. The record did not include a psychotropic treatment plan for these medications.
Plan of Correction:	*Resident #5 had the Psychotropic Treatment Plans completed for Sertraline and Trazadone and both were uploaded to their eChart, August Health *Resident #6 had the Psychotropic Treatment Plans completed for Haloperidol, Lorazepam and Trazadone and all 3 were uploaded to their eChart, August Health *All resident Physician Order Sheets to be audited to assure that there is a Psychotropic Order Sheet for each medication in this category. Any noted to be missing are to be obtained from the Provider and uploaded to the residents eChart, August Health. *The Providers seeing patients at the Branch had blank Psychotropic Treatment Plan forms (with instructions) added to their Provider binders. *Health & Wellness Dir., Coord., and RMAs instructed to request this form each time an order for a Psychotropic is received and not to submit it to be filled without this portion of the order. *Compliance to be monitored during weekly medication audits. Person Responsible: Health & Wellness Dir., Coord. or Designee Target Date of Completion: 10/25/23 & Ongoing
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that individualized service plan (ISP) included all assessed need. Evidence: 1. On 9-25-23, resident #1?s ISP did not include the resident?s allergy to sulfa antibiotic, perfume, and animal dander. The ISP also did not include the resident?s assessed need for oxygen. 2. Resident #2?s uniformed assessment instrument (UAI) dated 9-2-23 noted mobility assessed as no help needed. The ISP dated 7-14-23 noted resident needed mechanical help with mobility. 3. Resident #5?s UAI dated 3-20-23 social data noted resident is an active organ donor. Resident?s physical examination document dated 1-20-23 noted resident is allergic to Percocet. These were not documented on the resident?s ISP dated 3-20-23.
Plan of Correction:	*Resident #1 ISP was updated to include the allergies to sulfa antibiotics, perfume, and animal dander. Her assessed need for O2 will also be added. *Resident #2 will be reassessed in the area of mobility to assure that her needs are accurate and match on the UAI and ISP. *Resident #5 ISP will be updated to reflect that she is an organ donor and also that she is allergic to Percocet. *The UAI/ISP audit tool will be used to gather detailed information needed for both documents to assure that all identified needs are captured and records, as required. *The UAI/ISP audit tool will also be used by the Exec. Dir., or appropriate Designee, when signing off to assure that all assessed needs are properly recorded on both the UAI & ISP. Responsible Person: Health & Wellness Dir. or Coord, Admin. Asst. & Exec. Dir. Target Date of Completion:10/25/23 & Ongoing
Standard #:	22VAC40-73-450-D
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate an established an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP). Evidence: 1. On 9-25-23, resident #1?s ISP did not include hospice services being provided; neither the various services being provided to the resident. 2. Resident #6?s ISP did not include the resident received hospice services; neither the various services being provided to the resident (social worker, chaplain, aide, and skilled nursing).
Plan of Correction:	*Resident #1 ISP to be updated to include Hospice designation and services being provided. The Hospice provider?s Plan of Care will be utilized for this process. *Resident #6 ISP to be updated to include Hospice designation and services being provided. The Hospice provider?s Plan of Care will be utilized for this process. *The Special Needs List will be used to audit any other residents receiving Hospice services to assure that the required information is included on those ISPs. *The Special Needs List will be updated weekly by the Health & Wellness Dir. and/or Coord. and given to the Admin. Asst. each Monday to update and will be used to review ISPs to assure that the recent changes to the Special Needs list have been updated on the ISPs Person Responsible: Health & Wellness Dir. or Coord, Admin. Asst. & Exec. Dir. Target Date of Completion: 10/25/2023 & Ongoing
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed for significant change of a resident?s condition. Evidence: 1. On 9-25-23, resident #3?s uniform assessment instrument (UAI) dated 3-10-23 noted bathing and toileting assessed as independent. The ISP dated 3-10-23 noted resident needed mechanical help with bathing and toileting. Resident?s date of admit noted as 2-13-22. 2. Resident #4?s ISP dated 8-15-23 did not include description of what services will be provided to address identified, who will provide them, when and where services will be provided and expected outcome time frame. The UAI dated 8-15-23 noted dressing need assessed as mechanical help/ physical assistance; the ISP did not identify the mechanical help. Toileting and transferring need assessed as mechanical help. The ISP did not identify the mechanical help. Eating/Feeding assessed as no help, the ISP noted resident requires ?cueing to eat?. Bowel and bladder need assessed as less than weekly; the ISP did not address these needs. Walking need assessed as mechanical help; however, the resident does not walk. The resident is assessed as oriented; the ISP noted resident is forgetful, care support team to reorient, redirect and provide wayfinding. 3. Resident #6?s UAI dated 7-22-23 noted toileting assessed as mechanical help/physical assistance. The ISP dated 7-24-23 did not identify the mechanical help needed. Transfer need assessed as mechanical help. The mechanical help need is not identified. Wheeling and stairclimbing need assessed as not performed; these needs were not addressed on the ISP. Resident?s physician order dated 7-7-23 noted the resident allergic to Amoxicillin, Guaifenesin, Sudafed PE, Loratadine and Shrimp. These items were not on the resident?s ISP, in addition the ISP did not include dated need was identified and expected outcome and time frame for expected outcome. 4. Resident #7?s record included psychiatric services from a local agency, documented reports in record noted ?psychiatric follow-up? dated 5-30-23, 7-4-23 and 7-18-23. The resident?s UAI dated 3-8-23 noted behavior pattern as abusive/aggressive/disruptive less than weekly, yelling and hitting. Resident?s orientation assessed as disoriented, some spheres all the time to place and time.
Plan of Correction:	*Resident #3 will be reassessed in the areas of bathing and toileting to assure that her needs are accurate and match on the UAI and ISP. *Resident #4 had the ISP updated to reflect what services will be provided to include: who will provide those services, when and where those services will be provided, the expected outcome and the time frame. This will be for the following identified needs: dressing to include the type of mechanical help, toileting and transferring to include the type of mechanical help, eating/feeding to include human help on the UAI, bowel and bladder incontinence less than weekly on the ISP, The status of walking with the walker to be assessed and updated on the UAI & ISP. The level of orientation to be corrected on the UAI and reflected on the ISP. *Resident #6 ISP to be updated with the type of mechanical help needed with toileting and what type of mechanical help is needed with transfers. Wheelchair and stairclimbing not addressed on the ISP. The ISP will be updated to include the date the need was identified, expected outcome and timeframe for expected outcome. *Resident #7 ISP to be updated to include psychiatric services, the behavior patterns, and level of orientation. *All ISPs in August Health to be reviewed and updated to assure that all identified needs have a date when the need was identified, the expected outcome, and the time frame for the expected outcome. It will also include who is performing the service, when the service is performed, how the service is performed, where the service is performed and why the service is performed. *They will be reviewed, using the Special Needs List & UAI/Service Plan Audit Tool and then signed. Target Date of Completion: 10/25/2023 & Ongoing
Standard #:	22VAC40-73-470-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure either directly or indirectly, that the health care service needs of residents are met. Evidence: 1. On 9-25-23, resident #7?s record included a physician?s order dated 4-25-23 for occupational therapy, ?OT please eval and tx; cervical spinal stenosis, arthrosclerosis of c spine, paresthesia upper extremity, DJD c-spine? The record did not include documentation of therapy services. The individualized service plan did not include services beginning or ending.
Plan of Correction:	*Resident #7 record to be uploaded with the OT documentation ordered 4/25/23, and the ISP will be updated to include the beginning/ending dates. *Fox Rehab caseload list to be reviewed to assure that all current resident eCharts, August Health, have therapy notes scanned and uploaded. *The updated Special Needs list will be used weekly to monitor that the Fox Rehab notes have been uploaded into August Health. Person Responsible: Exec. Dir. & Admin. Asst. Target Date of Completion: 10/25/2023 & Ongoing
Standard #:	22VAC40-73-680-I
Description:	Based on observation, document reviewed, and staff interviewed, the facility failed to ensure the facility?s medication administration record (MAR) included all required information. Evidence: 1. On 9-25-23 during the medication pass observation with staff #3, resident #4?s Bumex did not include the diagnosis, condition, or specific indications for administering the drug or supplement. 2. Staff #3 acknowledged the resident?s September 2023 MAR did not include the diagnosis for Bumex.
Plan of Correction:	*Resident #4 had the Physician Order Sheet (POS) and MAR updated to reflect the diagnosis, condition, or specific indications for administering the medication. *A 100% audit of all Physician Order Sheets and MARs to be conducted to assure that all medications ordered have an a diagnosis. *Health & Wellness Dir. and/or Coord. to review all POS/MAR, at the time of move in and when new orders are received, to assure that a diagnosis is included for each medication. *This will be audited monthly when the Physician Order Sheets are printed and signed. Person Responsible: Health & Wellness Dir., Coord, or Designee. Target Date of Completion: 10/25/2023 & Ongoing
Standard #:	22VAC40-73-680-M
Description:	Based on observation, document reviewed, and staff interviewed, the facility failed to ensure medications ordered for PRN administration was available, properly labeled for the specific resident, and properly stored at the facility. Evidence: 1. On 9-25-23 during the medication pass observation with staff #3, resident #4?s PRN Acetaminophen and Aero chamber noted on the physician?s order dated 7-7-23 were not available. 2. Staff #3 acknowledged the resident?s PRN were not available on 9-25-23.
Plan of Correction:	*Resident #4 PRN Acetaminophen and Aero Chamber were re-ordered and arrived on 9/26/23 *A 100% audit to be conducted on all MARs with PRN medications to assure that they are on hand. *The 4 Hour Med Tech Refresher course training was provided to our RMAs on 10/10/23, which included the procedure for re-ordering routine & PRN medications. *This will be monitored weekly during the Medication Audits. Person Responsible: Health & Wellness Dir., Coord, or Designee Target Date of Completion: 10/10/23 & Ongoing
Standard #:	22VAC40-73-860-G
Description:	Based on observation and staff interviewed, the facility failed to ensure hot water at taps available to residents shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F. Evidence: 1. On 9-25-23 during a tour of the facility, the water temperature in room #112 tested at 122 degrees Fahrenheit.
Plan of Correction:	*The temperature settings for the 100 hall were adjusted down by the Maintenance Coord., and apartment #112 now reads at 115 degrees. He used his thermometer, which was calibrated. *Apartment #112 was monitored daily, at alternating times, for 3 days, and the temperature is holding steady. *This will continue to be monitored on the temperature log Person Responsible: Maintenance Coord. or Designee Target Date of Completion: 9/29/23 & Ongoing
Standard #:	22VAC40-73-930-B
Description:	Based on observation and staff interviewed, the facility failed to ensure that the signaling device permitted staff to determine the origin of the signaling or is audible and visible in a manner that permits staff to determine the origin of the signal. Evidence: 1. On 9-25-23 during a tour of the safe, secure unit with staff, the call bell in room #503 was pulled at 09:56 a.m. Staff members #4 and #6 were observed in the dining area of the unit. The inspector and staff #10 waited in the room and then came out of the room and waited for a staff to response to the call bell. Staff #10 stated the pager was observed on staff, however, neither staff #4 nor #6 responded to the call bell. At 10:06, the inspector inquired of staff if they heard the call bell. Staff #4 check the pager and stated not knowing the call bell had been alerted. Staff also stated that pagers do not always work, and the problem had been reported.
Plan of Correction:	*The Exec. Dir. duplicated the MBs doorbell and apt. #503 call bell on the evening of 9/25/23, and her pager operated properly. The other 3 pagers observed at the MBs Nurses Station and in the Med Room displayed the proper notifications for both the MBs doorbell and apt. #503. *All current Direct Care Staff will receive 1:1 training on how to operate, read, and reset the pagers used with the call bell system. This training will be documented. *All new hires will also receive 1:1 training on how to operate, read, and reset the pagers used with the call bell system. This training will also be documented. *This will be monitored by unannounced activation of various signaling devices to monitor Direct Care Staff response time. Person Responsible: Exec. Dir. & Maintenance Coord. Target Date of Completion: 10/25/23
Standard #:	22VAC40-73-940-A
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure it complied with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: 1. On 9-25-23, the fire inspection provided to the inspector was dated 5-3-22. 2. Staff #1 acknowledged the 5-3-22 fire inspection was the latest fire inspection for the facility.
Plan of Correction:	*The new Fire Marshall, Hope Scott, conducted the annual inspection on 10/12/23. She will forward the report on 10/13/23 and stated that things looked good. *It was explained that these inspections are required annually by DSS. *An Outlook reminder will be added for 11 months from today as a reminder to call the Fire Marshall?s office to schedule the annual inspection. Any difficulty with this process will be shared with the Exec. Dir. for follow up. Person Responsible: Maintenance Coord & Exec. Dir. Target Date of Completion: 10/12/23
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interviewed, the facility failed to ensure the first aid kits contained all required items. Evidence: 1. On 9-25-23 during a check of the first aid kit for the nursing station with staff #2, the antiseptic ointment was dated 08/2021. The first aid kit for the vehicle used to transport resident, antiseptic ointment was dated 02/2023. 2. Staff #2 acknowledged the first aid kit for the nursing station and vehicle?s antiseptic ointment were expired.
Plan of Correction:	*The Antiseptic Ointment was replaced in both the Assisted Living and Van First Aid Kits. *Bickford of Virginia Beach has modified their list of contents in their First Aid Kits to match the requirements of DSS to make the monthly inspection process more seamless. *The new checklist now includes an area to document expiration dates so that they can be replaced prior to their expiration. *The inspection of both First Aid Kits will be scheduled monthly, and those responsible for the inspection of both will be sent Outlook reminders. Person Responsible: Health & Wellness Dir. & Coord. Target Date of Completion: 10/9/23
Standard #:	22VAC40-73-980-H
Description:	Based on observation and staff interviewed the facility failed to ensure the availability of a 96-hour supply or emergency food and drinking water. At least 48 hours of the supply must be on site at any given time, of which the facility?s rotating stock may be used. Evidence: 1. On 9-25-23 during a tour of the facility, when asked about the facility?s emergency supply, staff #5 stated the facility did not have any water and the food supply was what was currently in the facility. The facility was expecting a food order from its local supplier, but no water was part of the food order. 2. Staff #1 acknowledged the facility did not have at least 48 hours of emergency supply on site on 9-25-23.
Plan of Correction:	*Our emergency water and food supplies were ordered from Sysco and did arrive on 9/27/23 along with our routine weekly food order. *The kitchen manager will write the expiration date in a visible location on each of the boxes of water and will monitor the expiration date to assure that our replacement inventory is ordered and arrives before the water on hand expires. *The Kitchen Manager was also instructed to store her non-perishable food items, to be used with the emergency menu, in a designated area in the dry storage room along with a copy of the corresponding menu so that the items can be easily inventoried and re-ordered, as needed. *This will be monitored quarterly during our Registered Dietician visits and annually during our Core-Checks. Person responsible: Kitchen Manager, Exec. Dir., and Registered Dietician