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 18, 2024 and July 29, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 07/18/2024 from 12:00 pm to 1:17 pm and 07/29/2024 from 10:30 am to 12:40 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 07/18/2024 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: 5 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were 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 #:	22VAC40-73-200-D
Complaint related:	No
Description:	Based on record review and interview, the facility failed to obtain a copy of the certificate issued or other documentation indicating that the person has met one of the requirements of subsection C of this section, which shall be part of the staff member's record in accordance with 22VAC40-73-250. Evidence: 1. Staff #3 works at the facility and was hired on 03/06/2023 as direct care staff; however, their record does not include a copy of the certificate issued or other documentation indicating that the person has met one of the requirements of subsection C of this section.
Plan of Correction:	Staff #3 documentation has been obtained to satisfy the requirements of section C.
Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on record review, the facility failed to ensure a fall risk rating is completed after a fall. Evidence: 1. Resident #2 fell per nursing notes on 01/17/2024; however, there is not a completed fall risk rating in the record of Resident #2 after the fall.
Plan of Correction:	Resident #2 record updated with fall risk rating.
Standard #:	22VAC40-73-470-F
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure when the resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional be secured immediately. Evidence: 1. Notes in Resident #4?s chart indicates the resident sustained a skin tear during a transfer with staff on 03/18/2024; however, it is documented treatment for the skin tear was initiated on 03/29/2024.
Plan of Correction:	Facility will ensure to document any incident in a timely manner to ensure treatment plan is being followed.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
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 #5?s Metoprolol order was changed on 06/13/2024 to receive 12.5 mg twice daily with the parameters to hold for SBP<110 or HR<55 and to notify provider if SBP <101 or >160. 2. Resident #5?s June 2024 MAR shows there were 22 occasions from 06/14/2024-06/26/2024 Resident #5?s Metoprolol was held due to the parameters; however, there was no documentation the provider was notified. 3. Resident #5?s June 2024 MAR shows there were 3 occasions from 06/14/2024-06/26/2024 Resident #5?s Metoprolol was documented as administered; however, the medication should have been held due to the parameters.
Plan of Correction:	Facility will ensure medications be administered in accordance with the physician?s or other prescriber?s instructions.