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: Sept. 17, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND

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: 09/17/2024 from 11:00 am to 1:45 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 09/05/2024 regarding allegations in the area(s) of: Resident Care and Related Services and Buildings and Grounds. 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: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 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: Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the complaint(s) 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 #:	22VAC40-73-460-E
Complaint related:	Yes
Description:	Based on documentation, the facility failed to regularly observe each resident for changes in physical, mental, emotional, and social functioning. Any notable change in a resident's condition or functioning, including illness, injury, or altered behavior, and any corresponding action taken shall be documented in the resident's record. The facility shall provide appropriate assistance when observation reveals unmet needs. Evidence: 1. The May MAR for Resident #1 notes the resident began to refuse multiple medications beginning 05/02/2024. 2. Progress notes for Resident #1 also indicate the resident was refusing medications and or food on several occasions to include notes written on 05/04/2024, 05/06/2024, and 05/12/2024. 3. Resident #1?s record indicated the resident did not see their mental health provider until 05/21/2024 for medication management and examination. 4. There was no indication in Resident #1?s records their primary care physician was notified of this change and altered behavior of Resident #1.
Plan of Correction:	Training in-service with caregiver staff to focus on proper communication processes when change occurs with residents, to include noting in AH, but to also let the nursing team know as well. HWD and HWC to follow up with providers and families to communicate changes in conditions.
Standard #:	22VAC40-73-460-H
Complaint related:	Yes
Description:	Based on observation and documentation, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with housekeeping. Evidence: 1. Resident #1?s ISP indicates the facility will clean their apartment weekly and as needed including removal of trash. 2. Staff #1 verified housekeeping documents on a paper posted on the back of resident apartments when the unit is cleaned. 3. Resident #1?s housekeeping documentation on the back of their apartment door indicates their apartment is to be cleaned on Wednesdays/Thursdays. 4. From May 15, 2024 to September 17, 2024, the following dates were listed on the posting in Resident #1?s apartment to document weekly cleaning: 5/15/24, 5/22/24, 5/29/24, 6/5/24, 6/12/24, 6/19/24, 7/3/24, 7/10/24, 7/24/24, 8/21/24, 9/4/24, 9/11/24. There were approximately 6 weeks missing from the documentation of weekly cleaning.
Plan of Correction:	ED and HWD to connect with Housekeeping and Maintenance personnel to train and educate on the housekeeping processes and documentation of duties. ED to ensure housekeeping is not only documenting for communication to residents, but also in a log for branch records. Training with the caregiver staff about this process to provide additional support.
Standard #:	22VAC40-73-550-C
Complaint related:	Yes
Description:	Based on observation and discussion, the facility failed to ensure any resident of an assisted living facility has the rights and responsibilities as provided in ? 63.2-1808 of the Code of Virginia. Evidence: 1. Resident #1 admitted to the facility on 10/13/2023. 2. Resident #1 indicated via the ?Photo and Audio/Video Release? (signed 10/18/2023) that they are not to be featured in publications and media for the facility. 3. Resident #1 is observed in a photo and or video posted by the facility on one of their social media platforms on the following days: 11/3/2023, 1/5/2024, 1/25/2024, and 3/5/2024. 4. Staff #1 acknowledged there were photos/video of Resident #1 on social media posted by the facility despite the ?Photo and Audio/Video Release? denial signed 10/18/2023.
Plan of Correction:	After reviewing all move in documents, ED to communicate with branch personnel being HWD, HWC, Family Advocate and Happiness Coordinator should a family choose to opt out of photos. This will be added to a list for branch leadership knowing?s.
Standard #:	22VAC40-73-580-F
Complaint related:	Yes
Description:	Based on record review, the facility failed to implement interventions as soon as a nutritional problem is suspected. These interventions shall include the following: weighing residents at least monthly to determine whether the resident has significant weight loss (i.e., 5.0% weight loss in one month, 7.5% in three months, or 10% in six months); and notifying the attending physician if a significant weight loss is identified in any resident who is not on a physician-approved weight reduction program and obtaining, documenting, and following the physician's instructions regarding nutritional care. Evidence: 1. Resident #1 had a significant weight loss of over 5% in one month from May 2024 (documented weighing 124.2 pounds) to June 2024 (documented weighing 117.4 pounds). 2. There was no documentation interventions were put into place nor was Resident #1?s attending physician notified of the significant weight loss. 3. There also were no monthly weights obtained in November 2023 or December 2023 for Resident #1.
Plan of Correction:	HWD to ensure monthly weights are completed and reviewed. Training with caregiver staff to communicate by not only noting in August Health, but also to the nursing team to ensure change in conditions have been presented. HWD to contact residents care provider and responsible party to inform of the changes. Lastly, HWD to present solutions and to formulate a plan of action for the resident with guidance from primary care provider. In addition, training support to all caregivers and nursing team on proper documentation process.