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: July 12, 2022

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

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: 7/12/2022 from 8:54 am to 3:45 pm. 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: 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: 8 Number of staff records reviewed: 4 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 #:	22VAC40-73-260-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 #1 (hire date 7/10/19), Staff #2 (hire date 7/13/17), and Staff #3 (hire date 2/17/22) work as direct care staff and do not have documentation of a current certification in first aid in their staff records.
Plan of Correction:	The insufficiency will be corrected as follows: Director has staff member signed up for CPR/First Aide renewal class in August. The following measures will be taken to ensure problems do not occur again: Director will have reoccurring CPR/First Aide Training classes offered every other month for new hires and any staff members requiring renewal. Persons responsible to implement and monitor corrective measure to ensure compliance: Director.
Standard #:	22VAC40-73-440-B
Description:	Based on record review, the facility failed to ensure that the uniform assessment instrument is completed as required by 22VAC30-110 for private pay individuals. Evidence: 1. The UAIs for Resident #1 (dated by the facility on 5/20/22), Resident #3 (dated 6/28/22), Resident #4 (dated by the facility on 7/27/22), and Resident #6 (date by the facility on 7/11/22) were not signed for approval by the administrator or designee.
Plan of Correction:	The insufficiency will be corrected as follows: Director has reviewed and signed UAI?s from residents charts. The following measures will be taken to ensure problems do not occur again: Nurse Coordinator will give UAIs to Director to sign and review after each completion of a new UAI for all residents prior to placing in residents chart. Nurses and Director will conduct an audit on all residents UAI?s (10 each week for the next 6 weeks) to ensure each resident current UAI is reviewed and signed by Director. Persons responsible to implement and monitor corrective measure to ensure compliance: Nurse Coordinator/Director.
Standard #:	22VAC40-73-520-I
Description:	Based on observation, the facility failed to ensure the current month's schedule be posted in a conspicuous location in the facility or otherwise be made available to residents and their families. Evidence: 1. During the tour of the facility on 7/12/22, the safe, secure environment was observed to have the June 2022 activity calendar and the daily activities for 7/11/22 posted.
Plan of Correction:	The insufficiency will be corrected as follows: The current months schedule has been posted up to date in conspicuous location for residents and families to see on 7/13/2022. The following measures will be taken to ensure problems do not occur again: Activities Director will ensure all activities calendar are ready to be posted day before the new month starts. Persons responsible to implement and monitor corrective measure to ensure compliance: Director/Activities Director.
Standard #:	22VAC40-73-610-B
Description:	Based on observation, the facility failed to post the menus for meals and snacks for the current week in an area conspicuous to residents. Evidence: 1. At the time of the inspection on 7/12/22, the menu for 7/12/22 was observed to be posted in the dining room; however, the menus for meals and snacks for the current week were not posted in an area conspicuous to residents.
Plan of Correction:	The insufficiency will be corrected as follows: The current weeks snacks are posted in bistro area for residents to see. Completed 7/14/2022, ongoing. Weekly meal menus are on the Flat Screen TV in dining room showcased for all residents and families to see. Completed 7/14/2022, ongoing. The following measures will be taken to ensure problems do not occur again: Kitchen Manager will ensure all snacks menus are ready to be posted day before the new week. Persons responsible to implement and monitor corrective measure to ensure compliance: Director/Kitchen Manager.
Standard #:	22VAC40-73-640-A
Description:	Based on documentation, the facility failed to implement their written plan for medication management which includes methods to ensure that each resident's prescription medications and any over-the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: 1. During review of the July MAR for Resident #7, Melatonin 3mg tab (2 tabs to be administered every night) and Trazodone 50mg tab (1/2 tab to be administered every night) have not administered to Resident #7 from 07/01/2022-07/11/2022 as the medication was not available.
Plan of Correction:	The insufficiency will be corrected as follows: Nurse Coordinator ensured missing medication is onsite for resident per orders 7/13/2022. The following measures will be taken to ensure problems do not occur again: Nurse Coordinator will audit med carts weekly to ensure any medications running low will be reordered in a timely manner to prevent missing medications for residents. Persons responsible to implement and monitor corrective measure to ensure compliance: Nurse Coordinator/Director.
Standard #:	22VAC40-73-650-B
Description:	Based on record review, the facility failed to ensure physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. The following medications on Resident #2?s MAR did not include a diagnosis: Multivitamin Adlt 50+ tab, Polyeth Glyc Pow 3350 NF, Gabapentin 300mg tab, Lidocaine Pa 4% pad, and Losartan Pot 50mg tab. 2. The following medications on Resident #3?s MAR did not include a diagnosis: Donepezil 10mg tab and Escitalopram 10mg tab. 3. The following medications on Resident #4?s MAR did not include a diagnosis: Eliquis 2.5mg tab, Latanoprost Sol 0.005% solution, Melatonin 3mg tab, Memantine 10mg tab, Metoprol Tar 25mg tab, PolyB/Trim Oph solution, Prorenal +D tabs, Quetiapine 25mg tab, Rivastigmine 4.5mg tab, Rosuvastatin10mg tab, Acetaminophen 325mg tab, Albuterol AER HFA, Cetirizine 10mg tab, Pantoprazole 40mg tab, and Mupirocin oin 2%. 4. The following medications on Resident #9?s MAR did not include a diagnosis: Aspirin Low 81mg tab, Losartan Pot 100mg tab, Preservision AREDs 2 caps, and Therems Multivit Tab.
Plan of Correction:	The insufficiency will be corrected as follows: Nurse Coordinator connected with pharmacy to ensure medications has diagnosis listed for Residents #2, #3, #4, and #9 on their medication list/POS on 7/14/2022. The following measures will be taken to ensure problems do not occur again: Nurse Coordinator will audit all residents POS for the upcoming month to ensure all medications has diagnosis. (20 residents medication list for the next 3 weeks.) Completed by 8/24/2022. Persons responsible to implement and monitor corrective measure to ensure compliance: Nurse Coordinator/Director.
Standard #:	22VAC40-73-720-A
Description:	Based on record review, the facility failed to ensure a valid written Do Not Resuscitate (DNR) order has been issued by the resident's attending physician; and that the written order is included in the individualized service plan. Evidence: 1. Upon review of Resident #2?s record, there are inconsistencies in regards to the resident?s code status. Resident #2 has a signed POST order (dated 11/11/21) with their last ISP (dated 2/15/22) indicating the resident as a DNR. However, the MAR as well as the last signed physician order sheet (signed 4/6/22) indicate the code status for Resident #2 as a Full Code. 2. Upon review of Resident #3?s record, the Physical Examination (dated 6/22/22) indicates the code status of the resident as a DNR. A document titled ?Resident Emergency Code Status? (dated 6/22/22) also states the code status of the resident is a DNR; however, it is not signed by the resident and only by the physician and Staff #5. The resident does not have a Durable DNR order indicating this is the wish of the resident in their record.
Plan of Correction:	The insufficiency will be corrected as follows: Nurse Coordinator corrected Residents #2, Medication List and POS has been reflected with the correct code status. Nurse Coordinator ensured resident #3 has current durable DNR form signed by resident and physician. The following measures will be taken to ensure problems do not occur again: Nurse Coordinator and Director will audit all resident charts to ensure proper Full Code and DNR forms are reflected in residents charts and medication lists. (10 residents each week for the next 6 weeks). Persons responsible to implement and monitor corrective measure to ensure compliance: Nurse Coordinator/Director.