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: June 13, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 06/13/2024 from 10:45 am to 12:50 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 06/05/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 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 #:	22VAC40-73-130-A
Description:	Based on interviews and record review, 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. On 06/05/2024, Resident #1 alleged staff twisted their arm while assisting the resident to bed the night prior. 2. Staff #1 confirmed Adult Protective Services was not notified of this allegation of abuse.
Plan of Correction:	All future suspected abuse will be reported to APS in accordance with state regulations and Bickford policy.
Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. Evidence: 1. Staff #3 was hired on 09/27/2023; however, there was not an initial TB risk assessment in their record.
Plan of Correction:	Audited staff records for TB screening and updated accordingly.
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 #2 works as direct care staff and does not have documentation of a current certification in first aid in their staff record.
Plan of Correction:	CPR and first aid class to be held in next 60 days at the community for all staff members.
Standard #:	22VAC40-73-680-E
Description:	Based on record review and interview, the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber be provided according to their instructions and documented. The documentation shall be maintained in the resident's record. Evidence: 1. Resident #1?s physician ordered for labs to be completed on 05/17/2024. The labs for Resident #1 were completed on 06/06/2024 with the results available to the physician on 06/13/2024.
Plan of Correction:	Physicians? orders and labs will be carried out as per state regulations and Bickford policy. HWD will communicate any obstacles as it relates with MD/NP to orders and document.