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: Jan. 9, 2024

Complaint Related: No

Areas Reviewed:

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

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/09/2024 from 10:00 am to 12:30 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 12/01/2023 regarding allegations in the area(s) of: Part VI Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 61 Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 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 #:	22VAC40-73-325-B
Description:	Based on record review, the facility failed to ensure the fall risk rating be reviewed and updated after a fall. Evidence: 1. Resident #1 fell on 12/23/2023. The last fall risk rating completed for Resident #1 was 5/30/2023.
Plan of Correction:	Nurses did not have a chance to complete being resident was taken out of the branch by family. In addition, fall risk ratings are completed within a day or two after fall.
Standard #:	22VAC40-73-450-E
Description:	Based on record review, the facility failed to ensure the individualized service plan be signed and dated by the resident or their legal representative. Evidence: 1. The ISP for Resident #1 (dated 7/19/2023) was not signed and dated by the resident or their legal representative.
Plan of Correction:	Family was notified of updated service plan and requested signature. Family did not sign. Nursing team will ensure all ISP's are signed by resident or responsible party and documentation indicates any refusals.
Standard #:	22VAC40-73-460-H
Description:	Based on record review, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met. Evidence: 1. Resident #1 was scheduled to received showers on Tuesdays and Saturdays in the evening. The following are the documented completion or attempts of bathing for Resident #1 from October 2023 to December 2023: 10/10/23 (refused), 10/11/23, 10/17/23, 10/28/23 (refused), 10/31/23 (refused), 11/7/23 (refused), 11/19/23, 11/21/23 (refused), 11/22/23, 11/28/23, 12/2/23 (refused), 12/12/23 (refused), and 12/16/23 (refused). 2. The documentation for Resident #1 does not indicate the resident received or attempted to receive bathing at least twice a week.
Plan of Correction:	HWD and HWC would shower resident together due to resident being combative and or refusing. Will be adding an additional in-service and training support for the staff to help with how to handle giving showers to residents with dementia and behaviors.
Standard #:	22VAC40-73-680-C
Description:	Based on record review, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: 1. The December 2023 MAR indicates the following medications were not available for administration at 8:00 AM on 12/15/2023 for Resident #1: Adlarity 10mg patch, Amlodipine 5mg tablet, Atenolol 50mg tablet, Atorvastatin 40mg tablet, Buspirone 10mg tablet, Divalproex 250mg tablet, Duloxetine 30mg capsule, Ensure, Memantine 10mg tablet, Omeprazole 20mg capsule, and Rivastigmine patch. 2. The Adlarity patch (a weekly medication) was also not available for administration on 12/1/23, 12/8/23, and 12/22/23 per the December 2023 MAR for Resident #1. 3. The Rivastigmine patch (a daily medication) was also not available for administration on 12/16/23 and 12/17/23 per the December 2023 MAR for Resident #1.
Plan of Correction:	HWD and HWC have planned an all nurse and med tech in-service for a refresher and training on the medication ordering process to ensure that all medications are received when needed.
Standard #:	22VAC40-73-680-D
Description:	Based on interview 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. 1. Resident #1 received an order for Paxlovid two times daily for 5 days dated 12/21/2023; however, the medication was not documented on the December 2023 MAR for administration. 2. Staff #1 confirmed the medication was not listed for administration on the December 2023 MAR for Resident #1.
Plan of Correction:	Medication was given and documented on paper log by med techs. HWD and HWC to ensure all orders are processed accordingly.