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: Feb. 27, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/27/2024 from 9:35 am to 11:00 am. 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 02/26/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 65 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: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Additional Comments/Discussion: The medication cart was reviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the (complaint(s)/self-report) 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-C
Complaint related:	Yes
Description:	Based on documentation, 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. During review of the MAR and physician orders for Resident #1, Refresh Tears Drops .5% OP is to be administered 3 times a day at 9 am, 12 pm, and 4 pm into each eye; however, there were 39 occasions from 11/29/2023 to 02/26/2024 it was not administered within the scheduled administration timeframe. During a review of the February 2024 MAR and physician orders for Resident #1, Erythromycin 5 mg ointment was to be administered 2 times daily before breakfast (7 am) and after dinner (6 pm) from 2/5/24-2/25/24 into lower conjunctiva in the left eye; however, it was not administered on 3 occasions within the scheduled administration timeframe. During a review of the February 2024 MAR and physician orders for Resident #1, Retaine MGD EMU .5-.5% was ordered to be administered into each eye every hour from 2/5/24-2/19/24 and changed to 4 times a day into each eye on 2/19/24; however, from 2/15/24-2/16/24, it was not documented as administered on 6 occasions and noted as unavailable for administration on 9 occasions. The medication was discontinued on the February 2024 MAR on 2/16/24 after the 2 pm dose. The medication was not documented for administration to the resident from 3 pm on 2/16/24 to 2/20/24. Additionally, from 2/19/24-2/26/24, it was documented as unavailable for administration on 3 occasions and was not administered on 3 occasions within the scheduled administration timeframe. During a review of the February 2024 MAR and physician orders for Resident #1, Retaine PM ointment is to be administered every night to both eyes; however, it was not administered on 2/23/25 as it was documented as unavailable for administration.
Plan of Correction:	An in-service has been scheduled for training on the medication administration process for all med techs and nurses. Training will be led by the Health and Wellness Director and Coordinator. In addition, all med techs and nurses will have reviewed and signed the administration delegation. The Health and Wellness Director will ensure that all medications from an outside provider be sent to Serviam Pharmacy in a timely manner to ensure proper administration times as ordered by the provider. Health and Wellness Director and Coordinator will perform med pass exceptions two times weekly.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. During a review of the physician orders for Resident #1, Retaine PM ointment was initially scheduled to be administered every night to both eyes at 8 pm; however, the order was changed to be administered at 11 pm on 2/5/24. 2. The February 2024 MAR for Resident #1 was not updated to reflect the change in order and Resident #1 has not received the medication within the ordered administration timeframe on 19 occasions since 2/5/24 as of 2/26/24.
Plan of Correction:	Health and Wellness Director and Coordinator to review and approve all new orders as they are submitted and review to ensure they are entered into the MAR.