VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bickford of Chesapeake
361 Great Bridge Boulevard
Chesapeake, VA 23320
(757) 819-9500

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: May 22, 2024

Complaint Related: No

Areas Reviewed:

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: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/22/2024 from 10:52 am to 11:37 am. 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 05/07/2024 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: 61 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 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 #:	22VAC40-73-1090-A
Description:	Based on record review and interview, the facility failed to ensure prior to admission to a safe, secure environment, residents have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. Resident #1 admitted to the safe, secure environment on 05/15/2024 and did not have a completed assessment of serious cognitive impairment in their record.
Plan of Correction:	The Health and Wellness Director obtained the completed assessment of serious cognitive impairment to include the signature from the nurse practitioner. The Health and Wellness Director or designee will ensure the completion of an assessment of serious cognitive impairment is completed by the nurse practitioner or independent clinical psychologist prior to a resident?s admission to a safe, secure environment to ensure continued compliance.
Standard #:	22VAC40-73-1100-A
Description:	Based on record review, the facility failed to obtain the written approval of one of the following persons listed in the standard of placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment. Evidence: 1. Resident #1 admitted to the safe, secure environment on 05/15/2024 and did not have documentation of approval for placement in a special care unit in their record.
Plan of Correction:	The Executive Director obtained the written approval of the resident?s POA for placement in a safe, secure environment. The Executive Director or designee will obtain written approval of one of the following persons listed in the standard prior to placing a resident with a serious cognitive impairment in a safe, secure environment to ensure continued compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the comprehensive ISP include a description of current identified needs and written description of what services will be provided to address identified needs. Evidence: 1. The notes for Resident #1 indicates the resident had exit seeking behavior on 04/26/2024 and 04/29/2024. 2. The UAI for Resident #1 dated 02/14/2024 indicates the resident wanders weekly or more and ?exit seeking behaviors more noticeable with sundowning.? 3. Resident #1 exited the main entrance unattended on 05/07/2024. 4. Prior to the 05/07/2024 incident, the current care plan dated 07/24/2023 for Resident #1 indicates the resident was not a wander/elopement risk with no noted behaviors. 5. The care plan for Resident #1 did not accurately address the resident?s exit seeking behaviors prior to the 05/07/2024 incident.
Plan of Correction:	The Health and Wellness Director updated the comprehensive ISP to address the resident?s exit seeking behaviors. The Health and Wellness Director or designee will ensure that the comprehensive ISP is updated with any changes as needed to ensure continued compliance.
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 prevention of falls and wandering from the premises. Evidence: 1. The notes for Resident #1 indicate on 04/26/2024 and 04/29/2024 the resident has shown exit seeking behaviors. 2. The ISP for Resident #1 dated 07/24/2023 does not indicate the resident as a wander/elopement risk with no noted behaviors. 3. Resident #1 exited the main entrance unattended, fell, and sustained a closed fracture of the nasal bone on 05/07/2024.
Plan of Correction:	Resident was transferred to the special care unit for safety and to prevent wandering from the premises unsupervised. The Health and Wellness Director or designee will monitor and provide supervision of resident schedules, care and activities, to include attention to specialized needs to ensure continued compliance.