VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bickford of Chesapeake
361 Great Bridge Boulevard
Chesapeake, VA 23320
(757) 819-9500

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Sept. 26, 2023 and Sept. 27, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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

Technical Assistance:

22VAC40-73-330 22VAC40-73-830 22VAC40-73-950 22VAC40-73-980

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/26/2023 and 09/27/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 63. 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: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 4 residents. The following were reviewed: resident and staff records, medication carts, water temperatures, and the staff schedule. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1110-A
Description:	Based on record review, the facility failed to ensure the licensee, administrator, or designee determine whether placement in the special care unit is appropriate for a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment. Evidence: 1. Resident #1 did not have documentation of the determination and justification on whether placement in the special care unit is appropriate by the licensee, administrator, or designee in their record.
Plan of Correction:	Placement in the memory care determination and justification will be obtained for each resident prior to moving into the memory care unit. This is to be completed by the Executive Director.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure each direct care staff member maintain 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. Staff #4 (hired 10/4/2022) work as direct care staff and does not have a current certification in first aid.
Plan of Correction:	Executive Director will do monthly audits of all direct care staff's CPR and First Aid status to ensure current.
Standard #:	22VAC40-73-290-B
Description:	Based on observation, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge, as provided for in this chapter, in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. Upon entry on 09/26/2023, the facility did not have the designated current on-site person in charge posted.
Plan of Correction:	This information is posted in front entry ways of both the assisted living and memory care. Executive Director to ensure any changes or updates are made if they occur.
Standard #:	22VAC40-73-320-A
Description:	Based on record review, the facility failed to ensure a physical examination by an independent physician be completed within 30 days preceding admission and contain the items identified in the standard. Evidence: 1. The physical examination for Resident #1 (completed 05/05/2022) and Resident #5 (completed 11/01/2022) indicated the residents require continuous licensed nursing care.
Plan of Correction:	All assessments are conducted by the Director of Health and Wellness and or the Health and Wellness Coordinator and are to be completed preceding admission. At this time, it should be determined if the potential resident is appropriate for assisted living.
Standard #:	22VAC40-73-350-B
Description:	Based on record review, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and failed to document that this was ascertained and the date the information was obtained. Evidence: 1. The following residents did not have a completed sex offender screening prior to admission in their record: Resident #2 (admitted 09/21/2023) completed 09/26/2023, Resident #3 (admitted 04/20/2023) completed 09/26/2023, and Resident #4 (admitted 10/31/2022) completed 11/03/2022.
Plan of Correction:	The assisted living facility shall ascertain, prior to admission, whether a potential resident is a registered sex offender if determined the potential resident will have a stay of three days or greater. The Administrator or designee will utilize the state approved sex offender registry database to ascertain this information.
Standard #:	22VAC40-73-440-A
Description:	Based on record review, the facility failed to ensure the UAI for residents be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition. Evidence: 1. Resident #3 admitted to the facility on 07/21/2023; however, the admitting UAI for Resident #3 was completed on 08/02/2023. Additionally, Resident #3 was admitted to hospice services on 09/15/2023; however, an UAI was not completed for this significant change. 2. Resident #5?s UAI (dated 07/22/2023) indicates the resident requires assistance for bathing, dressing, and toileting; however, it does not indicate the type of assistance the resident requires with these activities of daily living. The UAI also indicates the resident is incontinent of bladder weekly or more; however, during a medication observation and record review, Resident #5 utilizes a catheter.
Plan of Correction:	The assessment process shall be completed prior to accepting the potential resident to determine if they meet the criteria for assisted living residency at Bickford. Once residents move in, assessments are reviewed within 30 days of move in, every 180 days and as needed due to significant changes. Assessments are completed by the Director of Health and Wellness and or the Health and Wellness Coordinator.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure comprehensive individualized service plans include the expected outcome and time frame for expected outcome. Evidence: 1. The identified needs on the ISPs for Resident #2, Resident #3, Resident #4, and Resident #5 do not include the expected outcome and time frame for expected outcome.
Plan of Correction:	Currently service plans do indicate and show goals and time frames for the goals to be met in resident electronic service plan.
Standard #:	22VAC40-73-450-F
Description:	Based on record review, the facility failed to review and update individualized service plans as needed for a significant change of a resident?s condition. Evidence: 1. Resident #3 obtained a DNR and was admitted to hospice services on 09/15/2023; however, the resident?s ISP was not reviewed or updated for this significant change. Resident #3?s ISP (dated 08/02/2023) indicates the resident as a full code and does not reflect or address the resident?s admission to hospice.
Plan of Correction:	Director of Health and Wellness and Health and Wellness Coordinator will complete a significant change in condition with any changes for any resident, when changes occur.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to implement their methods to prevent the use of outdated medications based off their written plan for medication management. Evidence: 1. The following expired medications were observed on the medication carts at the facility: Acetaminophen 325mg tablets expired 05/04/2023 for Resident #5, Folic Acid 1mg tablets expired 06/29/2023 and Methotrexate Sodium 2.5mg tablets expired 09/02/2023 for Resident #9, Creon 12 capsules expired 01/16/2023 for Resident #10, Furosemide 20mg tablets expired 09/17/2023, Mirtazapine 30mg tablets expired 02/08/2023, Donepezil Hcl 10mg tablets expired 02/08/2023, Diclofenac Sodium Dr 75mg tablets expired 09/20/2022, and Ciprofloxacin Hcl 250mg tablets expired 07/03/2023 for Resident #11, Ipratropium .06% spray expired 11/2022 and Allopurinol 100mg tablets expired 11/18/2022 for Resident #12, and Aspirin 81mg tablets expired 06/2023 for Resident #13.
Plan of Correction:	Medication audits will occur once a week by the Director of Health and Wellness and Health and Wellness Coordinator. Quarterly audits will occur by Divisional Director of Health and Wellness.
Standard #:	22VAC40-73-680-D
Description:	Based on observation and record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. During a medication observation with Staff #10, Resident #4 was administered their morning medications at 9:24 am. 2. During a review of Resident #4?s medication order and MAR, their Tamsulosin .4 mg capsule is noted to be administered 30 minutes after a meal; however, at the time of administration, Resident #4 was observed eating their breakfast.
Plan of Correction:	Training to all medication aides regarding following proper orders for each medication for each resident. The medication management process is overseen by the Director of Health and Wellness.
Standard #:	22VAC40-73-680-H
Description:	Based on observation, record review, and interview, the facility failed to ensure at the time the medication is administered, the facility document on a medication administration record (MAR) all medications administered to residents, including over-the- counter medications and dietary supplements. Evidence: 1. During a reconciliation of the count of controlled substances with Staff #10 around 10:00 am on 09/26/2023, there were 36 capsules of Gabapentin 100mg for Resident #14 physically on the cart; however, the record indicated there were 35. Staff #10 acknowledged though they documented administering Resident #14?s 10 am Gabapentin that they had not done so. 2. The MAR for Resident #14 indicates Staff #10 documented having administered the medication at 9:48 am on 09/26/2023.
Plan of Correction:	Training to all medication aides regarding following proper orders for each medication for each resident, in addition random shadowing of the medication procedure by the Director of Health and or Health and Wellness Coordinator.
Standard #:	22VAC40-73-680-I
Description:	Based on record review, the facility failed to ensure the MAR include a diagnosis, condition, or specific indications for administering the drug or supplement. Evidence: 1. The following medications on Resident #3?s September 2023 MAR did not include a diagnosis: Aspirin 81mg tablet, Atorvastatin 40mg tablet, Duloxetine 20mg capsule, Ensure Vanilla, Hydrochlorot 12.5mg capsule, Levofloxacin 500mg tablet, Levothyroxin 75mcg tablet, Omeprazole 20mg capsule, and Vitamin D3 1000IU tablet.
Plan of Correction:	Health and Wellness Director and Health and Wellness Coordinator will ensure all medications are followed by a diagnosis from a physician.
Standard #:	22VAC40-73-700-2
Description:	Based on observation, the facility failed to post "No Smoking-Oxygen in Use" signs and enforce the smoking prohibition in any room of a building where oxygen is in use. Evidence: 1. During a tour of the facility, Resident #3 was noted to have an oxygen concentrator and tank in their apartment; however, there is not a ?No Smoking-Oxygen in Use? sign posted outside their apartment.
Plan of Correction:	Executive Director and or Director of Health and Wellness to ensure signage is posted when oxygen is in use.
Standard #:	22VAC40-73-930-D
Description:	Based on record review and interview, the facility failed to document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds for residents with an inability to use the signaling device. Evidence: 1. Staff #1 was unable to provide documentation of rounds no less often than every two hours for each resident with an inability to use the signaling device for review during the onsite inspection. There was no evidence indicating the rounds are completed at this time.
Plan of Correction:	Log created to track and monitor two hour rounds. This to include: resident, date, time and who completed the check.
Standard #:	22VAC40-73-940-A
Description:	Based on record review, the facility failed to comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: 1. The last inspection by the appropriate fire official was completed on 03/24/2022.
Plan of Correction:	Executive Director to ensure all inspections are completed and compliant with due dates.
Standard #:	22VAC40-73-950-F
Description:	Based on interview, the facility failed to review the emergency preparedness plan annually or more often as needed, documenting the review by signing and dating the plan, and making necessary plan revisions. Evidence: 1. Staff #1 could not provide documentation of an annual review of the emergency preparedness and response plan.
Plan of Correction:	VP of Health and Wellness to review annually. Executive Director to go over annually with staff rather in an all staff in-service and or individual assigned trainings.
Standard #:	22VAC40-73-960-B
Description:	Based on observation, the facility failed to ensure a fire and emergency evacuation drawing be posted in a conspicuous place on each floor of each building used by residents to include the location of the areas of refuge, assembly areas, fire alarm boxes, and telephones. Evidence: 1. During a tour of the facility, the emergency exit plans posted on the hallways did not include the areas of refuge, assembly areas, fire alarm boxes, or telephones.
Plan of Correction:	Will update emergency exit plans posted to include refuge areas, assembly areas fire alarm boxes and telephones.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. The following staff did not have a completed history record report completed on or prior to the 30th day of employment: Staff #2 (hired 08/14/2023) not obtained at the time of inspection, Staff #4 (hired 10/04/2022) completed 11/16/2022, Staff #5 (hired 07/20/2023) completed on 08/25/2023, Staff #6 (hired 05/03/2023) completed 07/18/2023, Staff #7 (hired 10/04/2022) completed 11/16/2022, Staff #8 (hired 04/14/2023) completed 08/25/2023, and Staff #9 (hired 05/03/2023) completed 07/24/2023.
Plan of Correction:	Once an offer of employment has been accepted, but prior to the start date Bickford will perform a background check through the Virginia Department of State Police utilizing the Non - Criminal Justice Interface.