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: May 4, 2023

Complaint Related: Yes

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

Technical Assistance:

22VAC40-73-325-C

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: 05/04/2023 from 10:50 am to 12:55 pm. 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 04/19/2023 and 05/02/2023 regarding allegations in the area(s) of: Part II Administration and Administrative Services, Part III Personnel, and Part IV Staffing and Supervision. Number of residents present at the facility at the beginning of the inspection: 54 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Part II Administration and Administrative Services and Part III Personnel. 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:	No
Description:	Based on record review and discussion, the facility failed to report to the regional licensing office within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. Through interviews with Staff #1 and Staff #2, it was alleged that Staff #4 punched Resident #1 in their stomach on 4/27/23. There was no documentation of this allegation in Resident #1?s record nor was this incident reported to the regional licensing office. 2. During a review of Resident #1?s record, it is documented that the resident fell on 3/21/23 and was sent to the ER where they received 5 staples to the back of their head. The Progress Notes for Resident #1 also documented Resident #1 was bitten by another resident on their finger. The facility did not make a report regarding either of these incidents about Resident #1 to the regional licensing office.
Plan of Correction:	The insufficiency will be corrected as follows: 5/4/23 reported incident to VDSS. Executive Director/Health and Wellness Director 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: 5/12/2023 - Educated staff on reporting procedures when any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident has occurred. Also educated staff on when a resident is sent out 911. A notification needs to be sent to Executive Director/Health and Wellness Director. Persons responsible to implement and monitor corrective measure to ensure compliance: Executive Director/Health and Wellness Director.
Standard #:	22VAC40-73-130-A
Complaint related:	No
Description:	Based on interviews, the facility failed to ensure all staff who are mandated reporters under ? 63.2-1606 of the Code of Virginia report suspected abuse, neglect, or exploitation of residents in accordance with that section. Evidence: 1. Through interviews with Staff #1 and Staff #2, it was alleged that Staff #4 punched Resident #1 in their stomach on 4/27/23. Staff #1 confirmed Adult Protective Services has not been notified of this incident at the time of inspection.
Plan of Correction:	The insufficiency will be corrected as follows: 5/5/23 reported to APS. Executive Director/Health and Wellness Director will send a report to Adult Protective Services to report within 24 hours when an allegation of abuse has allegedly occurred. The following measures will be taken to ensure problems do not occur again: 5/12/2023 - Educated staff on reporting procedures when any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident has occurred. A notification needs to be sent to Executive Director/Health and Wellness Director. Persons responsible to implement and monitor corrective measure to ensure compliance: Executive Director/Health and Wellness Director.
Standard #:	22VAC40-73-130-B
Complaint related:	No
Description:	Based on discussion, the facility failed to notify the resident's contact person or legal representative when a report is made relating to the resident as referenced in subsection A of this section, without identifying any confidential information. Evidence: 1. Through interviews with Staff #1 and Staff #2, it was alleged that Staff #4 punched Resident #1 in their stomach on 4/27/23. Staff #1 confirmed the facility has not notified the resident?s contact person or legal representative of this incident at the time of the inspection.
Plan of Correction:	The insufficiency will be corrected as follows: 5/5/23 reported to family. Executive Director/Health and Wellness Director will notify the resident?s contact person or legal representative when an allegation of abuse has allegedly occurred. The following measures will be taken to ensure problems do not occur again: 5/12/2023 - Educated staff on reporting procedures when any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident has occurred. A notification needs to be sent to Executive Director/Health and Wellness Director. Persons responsible to implement and monitor corrective measure to ensure compliance: Executive Director/Health and Wellness Director.