VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bickford of Virginia Beach
2629 Princess Anne Road
Virginia beach, VA 23456
(757) 821-0198

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: Feb. 5, 2025 and April 9, 2025

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 63.2 PROTECTION OF ADULTS AND REPORTING

Comments:

Type of inspection: Monitoring An on-site unannounced monitoring inspection conducted on 2-5-25 (Ar. 09:55 a.m./ dep 2:45 p.m.). Day 4-9-25 (Ar. 10:32 a.m./dep 12:35 p.m.). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported complaint was received by VDSS Division of Licensing on 1-3-25 regarding allegations in the resident abuse, negative treatment by staff. Number of residents present at the facility at the beginning of the inspection: 57 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: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 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 the (allegation(s)/self-report) 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 (Willie Barnes), Licensing Inspector at (757)-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-110-1
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure that staff was considerate and respectful of the rights, dignity, and sensitivities of a person who is aged, infirm, or disabled. Evidence: 1. On 2-5-25 and 4-9-25, the licensing inspector conducted an inspection regarding an emailed incident report from staff #1 on 1-3-25, informing the inspector that a resident in the safe, secure memory care unit was ?alleged to have been physically abuse by a staff (CC #1) on 1-1-25 at approximately 8:15 p.m. Resident #1 was at the nurse?s station with a lamp, phone, basket and other items in resident?s arm. CC#1 tried to get the items from the resident, but the resident refused/resistant items being taken. Two witnesses (staff #3 and CC #2) reported and provided written statements that CC#1, ?pushed resident down into a chair, squeezed resident?s hand, resident then hit CC#1. CC#1 then hit the resident?Resident #1 kicks CC#1 and CC#1 stomped on the resident?s right foot. Staff #3 and CC#2 goes to where the resident and CC#1 are on the memory care unit and intervenes in the situation. CC#1 then reaches around staff #3 and grab the back of resident #1?s neck. Staff #3 and CC#2 removes the resident from the situation and takes resident to resident?s bedroom. On the way to the bedroom CC#1, follows the resident and hit the resident on the buttocks.? 2. On 4-9-25, staff #1 acknowledged staff CC#1 was not considerate of a resident on the safe, secure memory care unit who is aged and infirmed and did not treat the resident with dignity and respect.
Plan of Correction:	*CC#1 was suspended upon notification of the incident and terminated once the investigation was concluded. *Adult Protective Services, VA Board of Nursing, and DSS Licensing Inspector were notified of this incident by the Executive Director upon being informed of the incident and was fully cooperative and transparent with each agency. *In additional to the Annual Resident Rights and Abuse Reporting training, conducted by Bickford of Virginia Beach every August, a dedicated in-service on Resident Rights, Abuse, and Managing Stress/Self Control will be held for our staff in May and conducted by a professional within the scope of their practice. Responsible Person: Executive Director
Standard #:	22VAC40-73-310-H
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions per 63.2-1805 D Code of Virginia for assisted living facilities. Evidence: 1. On 2-5-25, resident #1?s physician?s orders (POS) dated 1-8-25 documented resident prescribed Quetiapine (Seroquel) psychotropic medication. The facility did not have a psychotropic treatment plan for this medication. 2. Staff #1 acknowledged the resident did not have a treatment plan for the prescribed psychotropic medication.
Plan of Correction:	*Resident #1 Psychoactive Treatment Plan was obtained from her Provider who ordered it. *All resident records will to audited to assure that all with Psychoactive medication orders do have Psychoactive Treatment Plans on file. *Our Providers will be re-educated on the regulation regarding Psychoactive Treatment Plans and the need to provide one at the time they present us with an order for a Psychoactive medication, or we will not be able to administer the medication. Forms and instructions will again be placed in their binders. *Resident files will be audited against new orders, during weekly medication audits, to assure that all requiring Psychoactive Treatment Plans have them on file. Responsible Person: Health & Wellness Dir. & Health & Wellness Coord.
Standard #:	22VAC40-73-320-A
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure within 30 days preceding admission, the physical examination contain the required information. Evidence: 1. On 2-5-25, resident #1?s physical examination for admission to the facility?s dated 11-25-24 noted the resident was ambulatory. The resident?s assessment of serious cognitive impairment dated 11-25-24 noted the resident was unable to recognize danger or protect his/her own safety and welfare. According to staff #1, the resident was admitted directly to the facility?s safe, secure unit upon admission to the facility. 2. The resident?s risk assessment documenting the absence of tuberculosis (TB) in a communicable form was dated 10-29-24. Staff #1 confirmed the resident?s admit date was 12-10-24. 3. Staff #1 acknowledged the facility?s physical examination was not correctly documented for a resident admitted to the safe, secure unit. The physical examination document noted the resident was ambulatory (physically and mentally capable of self-preservation). The TB risk assessment was more than 30 days.
Plan of Correction:	*All resident Physical Examination forms, received by the resident?s Provider, will be signed off on by Nursing Leadership, or the Exec. Dir. in their absence, stating that it is complete, filled in correctly, and compliant. When Providers present documentation that does not meet the Standards, it will be returned to them for correction stating that their patient cannot be admitted until all paperwork is complete and compliant. *All new admission charts will be audited weekly for accuracy and compliance of Admission Forms. Responsible Person: Health & Wellness Dir., Health &Wellness Coord, Exec. Dir. & Admin Asst.
Standard #:	22VAC40-73-380-B
Description:	Based on record reviewed, documents reviewed, and staff interviewed, the facility failed to ensure the resident?s personal and social data document was kept updated. Evidence: 1. On 2-5-25, resident #1?s physical examination dated 11-25-24 noted resident allergic to Cephalexin. This allergy was also noted on the resident?s individualized service plan (ISP) dated 12-16-24, under the special care needs section. The resident?s personal and social data did not document Cephalexin as one of the resident?s allergies in the allergy section of the document. The personal and social data also noted the resident?s DNR (Do Not Resuscitate) was presented to the facility. The resident?s record did not have a signed/dated DNR from a physician. The resident?s ISP and Physician Orders dated 1-8-25 noted the resident as ?Full Code?. 2. Staff #1 acknowledged the resident?s personal and social data form was not kept updated.
Plan of Correction:	*August Health, our eChart software, assigns the Social Data Form to the family for completion, which increases the chances of that information not matching what the Provider documents on their forms. *These documents will be audited against each other and presented to the Provider and family for clarification. * All new admission charts will be audited weekly for accuracy and compliance of Admission Forms Responsible Person: Health & Wellness Dir., Health &Wellness Coord, Exec. Dir. & Admin Asst.
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed, document reviewed, and staff interviewed, the facility failed to ensure the resident?s individualized service plan (ISP) included all assessed needs. Evidence: 1. On 2-5-25, resident #1?s uniformed assessment instrument (UAI) dated 12-9-24 and 12-15-24 noted bathing need assessed as human help/supervision. The ISP dated 12-16-24 noted resident, ??walk into the shower using grab bars and sit on?shower chair?BFM will wash body with washcloth and soap starting with upper body, lower body?BRM will wash perineal area, BRM will rinse...body starting with the upper body, following by the legs, front perineal area, and rectal area?BFM will pat dry?entire body from upper body to lower extremities. Dressing assessed as human help/supervision. The ISP noted, ?BFM will assist?to decide what outfit is desired?then assist in applying to lower and upper extremities? BFM will?assist in removal of clothing and changing into pajamas?BFM will assist in dressing and undressing?? Toileting assessed as independent (no help). The ISP noted resident?transfer to and from commode with handrails, grab bars, walker and 1 BFM. Transferring assessed as independent (no help) ?resident ?can transfer from seated position to standing by using the arm of chair, 1 BFM, gait belt, walker or a wheelchair?. Walking, wheeling, stairclimbing and mobility assessed as no help. The ISP noted, resident is ?able to walk with assisted device (walker), uses walker and handrails to climb stair?. Hearing needs noted reminders and set up. The record did not include the use hearing aids or another assistive device. 2. The resident?s physical examination noted the resident to have physical therapy (PT) and occupational therapy (OT) services. The record included an initial evaluation and treatment for occupational services and physical therapy services and was electronically signed 1-12-25. ?OT plan: resident to be seen 2 visits per week for a total of 90 days. Certification period?1-7-25 to 4-6-25. ?PT plan: resident will be seen 3 visits per week for a total of 90 days. Frequency will be tapered to 2 visits per week by the end of the plan of care. Certification Period: 1-6-25 to 4-7-25?. 3. Staff #1 acknowledged the resident?s assessed needs and ISP did not agree and therapy services needs were documented on the ISP.
Plan of Correction:	* August Health, our eChart software, populates information for the ISP from both the UAI and the Resident Assessment. Because those two documents don?t match, the information populated in the ISP does not always agree with the UAI. We are in dialogue with August Health to determine how this will be addressed in the software. In the meantime, these documents may need to be printed, manually corrected, and uploaded into the file. *Resident #1 UAI and ISP were audited and manually correct to accurately reflect the identified needs. *All new and updated UAIs presented in August Health for Exec. Dir. signature will be printed by the Exec. Dir. and audited against the ISP and updated, if needed, prior to being uploaded into the eChart. Responsible Person: Health & Wellness Dir., Health &Wellness Coord, and Exec. Dir.
Standard #:	22VAC40-73-650-B
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements included all required information. Evidence: 1. On 2-5-25, resident #1?s physician order sheet (POS) dated 1-8-25 did not identify the diagnosis, condition, or specific indications for administering the following medications: (a) Century Mature Multivitamin, (b) DHEA 15mg, (c) Estradiol 0.7% gel, (d) Levothyroxine, (e) Memantine, (f) Methyl-Guard capsules, (g) Quetiapine, (h) Rivastigmine Patch, (i) Vitamin D plus K 5000 international unit (IU) and (j) Zinc Gluconate. 2. Staff #1 acknowledged the resident?s POS did not include all required information, diagnosis or specific conditions for medications.
Plan of Correction:	*Resident #1 Physician Order Sheet was audited and updated to assure that each medication has either a diagnosis or specific condition for each medication. *All resident Physician Order Sheets to be audited and updated to assure that each medication has either a diagnosis or specific condition for each medication. *Resident Physician Order Sheets will be audited against new orders, during weekly medication audits, to assure that each medication has either a diagnosis or specific condition for each medication. Responsible Person: Health & Wellness Dir., Health &Wellness Coord, and Exec. Dir.