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: July 2, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 07/02/2024 from 1:40 pm to 2:55 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 06/28/2024 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: 67 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 the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the (complaint(s)/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 #:	22VAC40-73-650-F
Complaint related:	No
Description:	Based on documentation, the facility failed to ensure whenever a resident is admitted to a hospital for treatment of any condition, the facility obtain new orders for all medications and treatments prior to or at the time of the resident's return to the facility. The facility shall ensure that the primary physician is aware of all medication orders and has documented any contact with the physician regarding the new orders. Evidence: 1. Resident #1 was admitted to the hospital on 06/13/2024; however, the facility did not obtain new orders for all medications prior to or at the time of the resident?s return to the facility on 06/15/2024. The facility received clarification on the hospital?s orders on 06/21/2024. 2. There was no evidence or documentation the primary physician of Resident #1 was made aware or contacted of all medication orders.
Plan of Correction:	The Health and Wellness Director has reached out to the resident?s PCP to reconcile their medication list. The Health and Wellness Director or designee will ensure that a discharge summary is received upon the resident?s return to the branch. The Health and Wellness Director or designee will communicate with the medication technician on duty to ensure that the discharge summary with all new orders for medications and/or treatments has been received, and if not received, will reach out to the hospital to request a copy. The Health and Wellness Director or designee will ensure that a copy of the discharge summary is referred to the PCP for review in order to ensure continued compliance.
Standard #:	22VAC40-73-680-C
Complaint related:	Yes
Description:	Based on documentation, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: 1. During a review of the June 2024 MAR for Resident #1, an Amlodipine 5mg tablet is to be administered once daily; however, it was not administered from 07/01/2024-7/08/2024 as it was unavailable for administration.
Plan of Correction:	The Health and Wellness Director or designee will complete a weekly audit of QuickMar to monitor for medication administration as ordered by the PCP to ensure continued compliance.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on documentation, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. The physician order noted on the discharge summary dated 06/15/2024 indicates Resident #1 should continue to receive Amlodipine 5mg tablet upon discharge; however, the resident did not receive this medication from 06/16/2024-06/20/2024 and was discontinued on 06/22/2024. 2. The physician order noted on the discharge summary dated 06/15/2024 indicates Resident #1 should continue to receive Aspirin 325mg tablet upon discharge; however, the resident did not receive this medication on 06/16/2024-06/20/2024, 06/23/2024-06/28/2024, and 06/30/2024. 3. The physician order noted on the discharge summary dated 06/15/2024 indicates Resident #1 should continue to receive Calcium+D3 600-800 tablet upon discharge; however, the resident did not receive this medication on 06/17/2024-06/20/2024 and 06/24/2024-06/27/2024. 4. The physician order noted on the discharge summary dated 06/15/2024 indicates Resident #1 should start Cefuroxime 500mg tablet 2 times daily for 7 days upon discharge; however, the June 2024 MAR has the start date of 06/21/2024 with Resident #1 receiving only 2 doses from 06/21/2024 to 06/28/2024. 5. The physician order noted on the discharge summary dated 06/15/2024 indicates a change in Resident #1?s Vitamin D medication. The order read to discontinue Vitamin D 50mcg 1 time daily upon discharge and to start Vitamin D 50000-unit capsule once a week on 06/21/2024. The June 2024 MAR indicates Resident #1 received Vitamin 50mcg tablet on 06/21/2024.
Plan of Correction:	The Health and Wellness Director or designee will complete a weekly audit of QuickMar to monitor for medication administration as ordered by the PCP to ensure continued compliance.