VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bickford of Suffolk
6860 Harbour View Boulevard
Suffolk, VA 23435
(757) 215-0058

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

Inspection Date: March 31, 2022 and April 26, 2022

Complaint Related: Yes

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 3/31/2022 from 12:45 PM to 2:35 PM and concluded 04/26/2022 from 9:10 AM to 11:30 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 03/24/2022 regarding allegations in the area(s) of: Part II Administration and Administrative Services, Part IV Staffing and Supervision, Part V Admission, Retention and Discharge of Residents, and Part VI Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Part II Administration and Administrative Services, Part V Admission, Retention and Discharge of Residents, and Part VI Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the complaint 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 #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on interview and record review, the facility failed to ensure any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident to the regional licensing office within 24 hours. Evidence: 1. On 4/26/2022, Staff #5 stated Resident #8 was sent out on 4/21/22 after a fall. There was only documentation in the 24 hour book on 4/21/22 that the resident fell with complaints of pain in head and back and was sent to the hospital. There was no additional information in Resident #8?s chart indicating or findings into the cause of the fall. Staff #5 was unable to provide an update on the resident?s condition or determine if the incident was reported to the regional licensing office. The assigned licensing inspector had not received notification of the incident prior to or at the time of inspection.
Plan of Correction:	The insufficiency will be corrected as follows: Director/Nurse Coordinator will send a report to VDSS licensing inspector to report within 24 hours. The following measures will be taken to ensure problems do not occur again: 6/11/2022 - Educated staff on reporting procedures when a resident is sent out 911. A notification needs to be sent to Director/Nurse Coordinator. Persons responsible to implement and monitor corrective measure to ensure compliance: Director/Nurse Coordinator.
Standard #:	22VAC40-73-325-B
Complaint related:	Yes
Description:	Based on interview and record review, the facility to ensure that a fall risk rating was completed at least annually and/or after a fall. Evidence: 1. On 4/26/2022, Staff #5 stated Resident #8 was sent out on 4/21/22 after a fall. Upon review of Resident #8?s record, there was not documentation of a fall risk rating being completed in the record prior to or after this fall.
Plan of Correction:	The insufficiency will be corrected as follows: Nurse Coordinator will complete a fall risk rating on resident. Complete by 6/18/2022. The following measures will be taken to ensure problems do not occur again: Nurse Coordinator will perform an audit on the resident?s chart and ensure fall rating is completed. Nurse Coordinator will complete fall risk rating every 180 days, after every fall, and as needed. Persons responsible to implement and monitor corrective measure to ensure compliance: Nurse Coordinator.
Standard #:	22VAC40-73-460-H
Complaint related:	Yes
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. Documentation for showers between 4/1/2022-4/24/2022 were reviewed to ensure bathing is occurring at least twice a week, but more often if needed or desired. The following are the documented completion or attempts of bathing on the records reviewed: Resident #1 - 4/1, 4/5, Resident #2 - 4/4, Resident 3 - 4/4 (refused), 4/7, 4/10, 4/11, 4/14. 4/18, Resident 4 - 4/6 (refused), 4/10, 4/13 (refused), 4/17, 4/23 (refused) Resident #5 - 4/8 (refused), 4/10, 4/17, 4/10 (refused), 4/22, Resident #6 - 4/6, Resident #7 - 4/11, 4/18, Resident #8 - 4/5 (refused), 4/8, 4/15, 4/188, 4/19 (refused), Resident #9 - 4/1, 4/5, 4/15 (refused), Resident #10 - 4/4 (refused), 4/7 (refused). The documentation for Resident #1, Resident #2, Resident #6, Resident #7, Resident #9 and Resident #10 does not indicate the residents are receiving bathing at least twice a week.
Plan of Correction:	The insufficiency will be corrected as follows: Director and Nurse Coordinator will create a shower book to document resident showers and refusals. Staff will have to sign and report resident showers. Shower book will display resident scheduled shower days. Complete by 6/24/2022 The following measures will be taken to ensure problems do not occur again: Nurse Coordinator will check shower book weekly to ensure showers are addressed and properly given to resident. Director will check shower book monthly. Persons responsible to implement and monitor corrective measure to ensure compliance: Nurse Coordinator/Director.