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: Nov. 4, 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: 11/04/2024 from 10:10 am to 11:38 am. 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 10/30/2024 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: 64 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: 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 #:	22VAC40-73-325-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 #1 fell per nursing notes on at least 9 occasions in October 2024; however, there were only 3 fall risk ratings completed in October 2024 for Resident #1 in their record.
Plan of Correction:	Resident #1 has passed away on hospice services. The Health and Wellness Director or designee will ensure that a Fall Risk Assessment is completed at least annually and following each fall for our residents to ensure continued compliance.
Standard #:	22VAC40-73-460-B
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure care provision and service delivery be resident-centered to the maximum extent possible and include prompt response by staff to resident needs as reasonable to the circumstances. Evidence: 1. On 10/21/2024, the average time for staff to respond to Resident #1?s call bell was approximately 42 minutes per documentation. 2. On 11/14/2024, the call bell for Resident #1 was pushed at 10:12 am. Staff did not respond to the call bell until 10:41 am upon notification the call bell was pushed. 3. Staff #2 indicated staff should respond to call bells within 5 minutes.
Plan of Correction:	Re-education was provided to the staff regarding the length of time expected to answer a resident?s call bell. The Executive Director or designee will ensure that there is a prompt response by the staff to resident needs as reasonable to the circumstances.
Standard #:	22VAC40-73-460-D
Complaint related:	Yes
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. Evidence: 1. Resident #1 fell per nursing notes on at least 9 times in October 2024 and 3 times in September 2024; however, Resident #1?s care plan was last updated 06/30/2024 and there were no additional interventions initiated to prevent or reduce risk of subsequent falls.
Plan of Correction:	Resident #1 has passed away on hospice services. The Health and Wellness Director or designee will ensure that an updated ISP is completed for a significant change of a resident?s condition to include attention to specialized needs, such as prevention of falls.
Standard #:	22VAC40-73-930-D
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff make rounds no less often than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility. The facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. Evidence: 1. Staff #1 acknowledged Resident #1 is unable to utilize the signaling device. 2. There was no documentation of rounds no less often than every two hours after Resident #1 has gone to bed each evening until the resident has arisen each morning.
Plan of Correction:	Re-education was provided to the staff regarding the requirement of making rounds every two hours for residents with an inability to use the signaling device. The Executive Director or designee will ensure that there is documentation of rounds no less often than every two hours once a resident with the inability to use the signaling device has gone to bed each evening until the resident has arisen each morning unless a request has been made for a different frequency by the resident or POA.