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 10, 2023

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: 7/10/2023. 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: 56 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 #3 (hire date 05/01/2023) works as direct care staff and does not have documentation of a current certification in first aid in their staff records.
Plan of Correction:	The insufficiency will be corrected as follows: Staff #3 will attend First Aid Class on 8/1/23. The following measures will be taken to ensure problems do not occur again: BFM?s will complete first aid within 30 days of hire. Persons responsible to implement and monitor corrective measure to ensure compliance: Executive Director.
Standard #:	22VAC40-73-330-A
Description:	Based on record review, the facility failed to ensure a mental health screening be conducted prior to admission if behaviors or patterns of behavior occurred within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual. Evidence: 1. Resident #3 admitted to the facility on 06/14/2023. The hospital discharge summary (dated 06/14/2023) indicates Resident #3 has history of dementia with behavioral disturbances and wandering. The mental health screening for Resident #3 (dated 06/14/2023) indicates the screening is not applicable despite the information reflected in the discharge summary.
Plan of Correction:	The insufficiency will be corrected as follows: Resident #3 mental health screening completed on 7/14/23. The following measures will be taken to ensure problems do not occur again: Director will audit chart upon move in to ensure a mental health screening was conducted prior to admission if the admission meets the criteria for needing completion. Persons responsible to implement and monitor corrective measure to ensure compliance: Executive Director/Health and Wellness Director.
Standard #:	22VAC40-73-430-H-1
Description:	Based on record review and interview, the facility failed to ensure a dated discharge statement signed by the licensee or administrator that contains the information listed in the standard to be provided to the resident and, as appropriate, his legal representative and designated contact person at the time of discharge. Evidence: 1. The record for Resident #8 did not contain a written discharge statement. 2. Staff #5 acknowledged Resident #8 did not have a written discharge statement retained in the resident?s records.
Plan of Correction:	The insufficiency will be corrected as follows: Executive Director will ensure a dated discharge statement signed by the licensee or administrator that contains the information listed in the standard to be provided to the resident or legal representative at the time of discharge. The following measures will be taken to ensure problems do not occur again: Director will audit chart upon discharge to ensure a discharge statement was provided to the resident or legal representative at the time of discharge. Persons responsible to implement and monitor corrective measure to ensure compliance: Executive Director.
Standard #:	22VAC40-73-520-I
Description:	Based on observation, the facility failed to ensure the current month's schedule of activities 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 7/10/2023, the safe, secure environment did not have the current month?s activity calendar posted.
Plan of Correction:	The insufficiency will be corrected as follows: 7/11/2023 Happiness Coordinator posted the current month?s schedule of activities in the safe, secure environment. The following measures will be taken to ensure problems do not occur again: Happiness Coordinator/Executive Director will audit the safe, secure environment daily to ensure the current month?s activity calendar is posted. Persons responsible to implement and monitor corrective measure to ensure compliance: Happiness Coordinator/Executive 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. During the tour of the facility on 7/10/2023, the menus for snacks for the current week were not posted in an area conspicuous to residents.
Plan of Correction:	The insufficiency will be corrected as follows: 7/11/2023 Breadbasket Manager posted the current week?s menu for meals and snacks in an area conspicuous to residents. The following measures will be taken to ensure problems do not occur again: Breadbasket Manager/Executive Director will audit daily to ensure the current week?s menu for meals and snacks are posted in an area conspicuous to residents. Persons responsible to implement and monitor corrective measure to ensure compliance: Breadbasket Manager/Executive Director.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication. Evidence: 1. The following expired medications were observed in the medication carts at the facility: PRN Hydrochlorothiazide 12.5 tablets expired 06/30/2023 for Resident #1, Arthritis Pain 650 mg tablets expired 07/02/2023 for Resident #4, PRN Famotidine 20 mg tablets expired 07/03/2023, PRN Gas Relief 80 mg tablets expired 07/03/2023, and PRN Naproxen Sodium 220 mg tablets expired 07/02/2023 for Resident #9, PRN Loperamide 2 mg capsules expired 07/08/2023, Alphagan Solution expired 04/2023, and PRN Acetamin 500 mg tablets expired 04/26/2023 for Resident #10, PRN Omeprazole 40 mg capsules expired 06/22/2023 for Resident #11, PRN Acetamin 500 mg tablets expired 07/03/2023 for Resident #12, PRN Loratadine 10 mg tablets expired 05/29/2023 for Resident #13, PRN Acetaminophen 325 mg tablets expired 07/02/2023 for Resident #14, PRN Acetaminophen 650 mg tablets expired 06/24/2023, PRN Esomepra 40 mg capsules expired 06/24/2023, and PRN Ibuprofen 800 mg tablets expired 06/24/2023 for Resident #15, and Methocarbam 750 mg tablets expired 07/06/2023 for Resident #16.
Plan of Correction:	The insufficiency will be corrected as follows: Residents #1,#4,#9, #10,#11,#12,#13,#14,#15, and #16 expired medications were removed from cart 7/10/2023. The following measures will be taken to ensure problems do not occur again: Health and Wellness Director and Health and Wellness Coordinator will perform weekly medication cart audits and remove expired medications. Persons responsible to implement and monitor corrective measure to ensure compliance: Health and Wellness Director/Executive Director.
Standard #:	22VAC40-73-680-C
Description:	Based on observation and interview, 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. At 10:20 am on 07/10/2023, Staff #2 was observed administering 9:00 am scheduled medications to Resident #4. At approximately 10:23 am, Staff #2 indicated 11 residents had not received their 8:00 am medications with 15 residents having not received their 9:00 am scheduled medications as well. The MAR indicated this was around 104 medications and or treatments over one hour after their dosing schedule.
Plan of Correction:	The insufficiency will be corrected as follows: Medications will be given according to doctor?s orders no earlier or later than one hour from standard dosing schedule. The following measures will be taken to ensure problems do not occur again: Weekly Med variance reports to be run to ensure compliance with medication times and follow up with physician(s) to investigating whether we can adjust or change times to be in compliance if needed. Educate BFM?s regarding medication management through annual in-service, and individually when necessary. Persons responsible to implement and monitor corrective measure to ensure compliance: Health and Wellness Director and Health and Wellness Coordinator.
Standard #:	22VAC40-73-680-D
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. Resident #7 has an order to be administered 1 Midodrine 10 mg tablet by mouth 3 times daily with food with a parameter to hold for SBP >110. Per Resident #7?s MAR, the resident?s SBP was greater than 110 and the resident was administered Midodrine on the following days: 07/01/2023 (1 dose), 07/03/2023 (2 doses), 07/05/2023 (1 dose), and 07/06/2023 (1 dose). Per Resident #7?s MAR, the resident?s SBP was less than 110 and the resident was not administered Midodrine on the following days: 07/02/2023 (2 doses), 07/04/2023 (2 doses), and 07/05/2023 (1 dose).
Plan of Correction:	The insufficiency will be corrected as follows: Health and Wellness Director met with RMA?s and reviewed physician?s order for resident #7?s Midodrine. The following measures will be taken to ensure problems do not occur again: Order?s will be reviewed, processed, and approved in quickMAR for accuracy upon receipt. Weekly Med Audits to be done to ensure order accuracy and med cart orderliness. Persons responsible to implement and monitor corrective measure to ensure compliance: Executive Director/Health and Wellness Director/Health and Wellness Coordinator.
Standard #:	22VAC40-73-930-D
Description:	Based on record review and interview, the facility failed to document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds for residents with an inability to use the signaling device. Evidence: 1. During a review of the evening rounding documentation in the safe, secure environment on 07/10/2023, staff were unable to provide documentation of rounds no less often than every two hours for each resident with an inability to use the signaling device after 06/20/2023.
Plan of Correction:	The insufficiency will be corrected as follows: Resident Apartment night time Safety Checks Daily Log (VA) implemented for residents in Mary B?s per Bickford policy. The following measures will be taken to ensure problems do not occur again: ISP?s will identify need for safety checks due to inability to use signaling device in safety section. Executive Director/Health and Wellness Director will review the night time safety check daily log daily. Persons responsible to implement and monitor corrective measure to ensure compliance: Executive Director/Health and Wellness Director.