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: Oct. 11, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/11/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Two self-reported incidents were received by VDSS Division of Licensing on 9/13/2023 and 9/26/2023 regarding allegations in the area(s) of: Part V Admission, Retention and Discharge of Residents, Part VI Resident Care and Related Services, and Part X Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. Number of residents present at the facility at the beginning of the inspection: 61. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were: Part VI Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-70-A
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. During a review of Resident #1?s record, it is documented that on 7/21/23 police were called to the facility as Resident #1 was unable to be redirected after throwing several objects. The resident also broke two courtyard windows. 2. Staff #1 acknowledged the facility did not make a report regarding this incident to the regional licensing office.
Plan of Correction:	The insufficiency will be corrected as follows: - Executive Director/Health and Wellness Director will send a report to 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. The following measures will be taken to ensure problems do not occur again: - 10/19/2023 - 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 #:	22VAC40-73-460-D
Description:	Based on record review, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises. Evidence: 1. On 9/13/23, Resident #1 who resided in the safe, secure environment broke a window in another resident?s apartment and exited the facility. Resident #1 was found ?face down in the mud? in a neighboring housing community.
Plan of Correction:	The insufficiency will be corrected as follows: - Service plans updated to reflect supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises. The following measures will be taken to ensure problems do not occur again: - Director will review ISP?s when completed to ensure they properly reflect supervision of resident schedules, care, and activities, including attention to specialized needs. Persons responsible to implement and monitor corrective measure to ensure compliance: - Executive Director/Health and Wellness Director