Virginia DSS · Assisted Living Facility

Bickford of Virginia Beach

📍 2629 Princess Anne Road, Virginia Beach, VA, 23456

ID 45688One Year licenseActive
25
Inspections
On record
24
With violations
Visits that cited something
1
Clean visits
Nothing cited
171
Violations cited
Individual findings
74
Standards cited
Distinct rules
14
Complaint visits
Prompted by a complaint

Bickford of Virginia Beach was inspected 25 times between January 13, 2021 and December 22, 2025 by the Virginia Department of Social Services. 24 of those visits ended with violations cited and 1 with none. Across that history VDSS cited 171 violations under 74 distinct standards. 14 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 22 of these 25 are still on the state's site; the other 3 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
11/11/2026
Administrator
Loryn Duncan-Marcil
Licensing inspector
Tiffany Jefferson
Inspector phone
(804) 317-0413
Approved for
Special Care Unit · Assisted Living

Inspection History

25

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

December 22, 2025Complaint survey2 violations
Inspection dates
12/22/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
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: 12/22/2025 9:27 am-1:40 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 10/6/2025 regarding allegations in the area(s) of: Resident Care and Related Services Personnel Staff and Supervision Number of residents present at the facility at the beginning of the inspection: 60 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: The Licensing Inspector observed resident activity, conducted a tour of the facility, reviewed resident bedrooms, and interviewed residents and staff. Additional Comments/Discussion: n/a An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-250-D
Based on a review of staff records, the facility failed to ensure that each staff person submits the results of a tuberculosis (TB) risk assessment on or within seven days prior to the first day of work at the facility and that each staff person submits the results of a risk assessment annually.
Evidence
  1. The TB assessment presented for Staff # 3 during the on-site inspection was incomplete. None of the screening elements were checked.
  2. Staff #1 and Staff #2 acknowledged that the TB screening form was incomplete.
  3. Photographic evidence available
Plan of correction
Not published by VDSS.
22VAC40-73-260-A
Based on a review of documentation and interviews, the facility did not ensure that each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.
Evidence
  1. When requested, Staff #1 was unable to provide documentation of Staff # 3 having current certification in First Aid.
Plan of correction
Not published by VDSS.
August 13, 2025Complaint survey3 violations
Inspection dates
08/13/2025, 08/22/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint An unannounced complaint inspection was conducted on 8-13-25 and 8-22-25. (Ar 09:05 a.m./Dep 12:05 p.m.) 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 8-12-25 regarding allegations in the resident care and related services and buildings and grounds. Number of residents present at the facility at the beginning of the inspection: 58 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: N/A Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: resident’s room and dog on 8-13-25 Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-860-I
Based on observation and staff interviewed, the facility failed to ensure cleaning supplies and other hazardous materials were stored in a locked area.
Evidence
  1. On 8-22-25, two (2) bottles of cleaning spray were observed in the hallway on a storage bin located near resident #2’s room- #307.
  2. Staff #1 acknowledged the cleaning items should have been placed in a locked storage.
Plan of correction
*The 2 bottles of disinfectant, located outside of Resident #2 apartment, were immediately removed by the Executive Director. *The Housekeeper was re-educated on the importance of properly securing all cleaning products in a locked area. *Cleaning storage areas and carts will be checked, during routine rounds, to assure that they are locked and that all cleaning supplies or other hazardous materials are properly secured in a locked area while not in use by staff. Person Responsible: Exec. Dir., Health & Wellness Dir., Health and Wellness Coord., or Designee Target Completion Date: 8/22/25
22VAC40-73-870-B
Based on inspection of resident’s room and BFMs interviewed, the facility failed to ensure a resident’s room was free from foul, stale, and musty odors.
Evidence
  1. On 8-13-25, following a complaint of resident in room 305 having an odor and resident not able to care for self and dog, the inspector and staff # 3 went to room 305. The room had a very strong odor of urine and dog food. Interviews with BFMs stated, the resident’s dog urinates on the resident’s bed and floor. Pads were placed on the floor for the dog, but the dog will not always use the pad. Staff #3, stated the administrator was aware of the situation with the dog and the resident’s family was also notified. The ISP dated 8-6-25 noted, “resident’s apartment will be clean and free of odor”.
  2. Staff #1 acknowledged that the resident was no longer able to care for self and the dog. Staff #1 stated contacting the family to address the situation and possible relocate the resident to the facility’s safe, secure unit (Mary Bs locked/secure unit because of cognitive decline).
Plan of correction
*As a follow up to several recent conversations with Resident #1 son and daughter about the dog and the inability to properly care for the pet, they picked up the dog that same day on 8/13/2025. *Resident #1 apartment carpet was cleaned again and deodorized, as well as any other items that have an odor. The son of Resident #1 assisted with this process. *There are no other residents with dogs or foul odors caused by pets. *If a resident with a pet is no longer able to care for their pet, the family/POA will be asked to make other arrangements for the pet and given a deadline. Revised pet policies are in place within our move-in packets that took effect on 9/1/25. Person Responsible: Executive Director Target Completion Date: 9/1/2025
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s individualized service plan (ISP) included all assessed needs.
Evidence
  1. On 8-22-25, resident #1’s uniform assessment instrument dated 8-6-25 noted the resident eating/feeding need assessed as independent. The ISP dated 8-6-25 noted resident need, “meal reminders or cueing to eat”. Walking need assessed as mechanical help/physical assistance, the ISP noted, “resident is able to walk without assistive devices…Resident will walk dog three times a day, 8am., 2pm and 7pm.” The resident was observed using a wheelchair and pushed by staff, and unable to walk. The resident is assessed as disoriented, some spheres/some of the time, time and place spheres affected. The ISP did not include what services staff would provide to meet resident’s assessed need.
Plan of correction
*Resident #1 ISP was updated to include all assessed needs with regards to eating/feeding, mechanical devices used with ambulation, and any references to the dog which no longer lives in the apartment. * Moving forward, all assessed needs will be compared to the ISP and audited by the Health and Wellness Coord. to assure that all assessed needs are reflected on the ISP. The audited and corrected (if needed) ISP will be uploaded and maintained in August Health. *These will be spot checked during routine weekly eChart audits by the E.D. or designee. Person Responsible: Health & Wellness Dir., Health and Wellness Coord., and E.D./Designee Target Completion Date: 9/23/2025
August 12, 2025Inspection11 violations
Inspection dates
08/12/2025, 08/13/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 PROTECTION OF ADULTS AND REPORTING22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal An unannounced renewal inspection conducted on 8-12-25 (Ar 07:46 a.m./Dep 17:30 p.m.) Day 2 (Ar 09:15 am./Dep 19:10 p.m.). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 59 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 6 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 9 Observations by licensing inspector: breakfast meal, medication pass observation, exercise activity (SCU), first aid kits, emergency supplies Additional Comments/Discussion: 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 (Willie Barnes), Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure individualized service plan (ISP) was reviewed and updated to include all assessed needs.
Evidence
  1. On 8-12-25, resident #1’s record review was conducted with staff #2. Resident #1 receives skilled nursing services for a Foley Catheter from a home health agency. This foley care need was not documented on resident #1’s ISP dated and signed on 5-19-25 by the legal representative, and 1-31-25 by the facility staff. Resident’s start of care of services was noted as 8-11-24. Resident’s physician’s progress notes documented Foley catheter on 6-16-25, 5-1-25; 4-8-25 and 4-2-25. The resident’s uniformed assessment instrument (UAI) dated 1-31-25 and signed by staff #1 (5-5-25) and staff # 1 (4-17-25) assessed resident’s orientation as “disoriented all spheres, some of the time…spheres affected: place and time”. The ISP did not include what services would be provided by the facility to address the resident’s orientation.
  2. Resident #2’s UAI dated 5-1-25 and signed by staff #1 (5-5-25) and staff #2 (5-4-25) noted resident’s behavior assessed as “appropriate”; the ISP signed by legal representative on 5-5-25 (staff #1 on 5-5-25 and staff #2 on 5-4-25) documented resident, “wanders throughout the building. BFM will provide personalized activities when resident has wandering concerns”. Wandering is not assessed on the UAI.
Plan of correction
PLAN: Resident #1 and resident #2 had their ISP's updated to include all of their assessed needs. Moving forward, all assessed needs will be compared to the ISP and audited by the Health and Wellness Coord. to assure that all assessed needs are reflected on the ISP. The audited and corrected (if needed) ISP will be uploaded and maintained in August Health. These will be spot checked during routine weekly eChart audits by the E.D. or designee. Person Responsible: Health & Wellness Dir., Health and Wellness Coord., and E.D./Designee Target Date of Completion: 9/15/25 and ongoing
22VAC40-73-680-M
Based on observation, record reviewed, and staff interviewed, the facility failed to ensure medications ordered for PRN administration was available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. Based on observation, record reviewed, and staff interviewed, the facility failed to ensure medications ordered for PRN administration was available, properly labeled for the specific resident, and properly stored at the facility. Evidence:
  2. On 8-12-25, during the medication pass observation with staff #5, resident #1’s physician’s order dated 7-17-25 and August 2025 medication administration record (MAR) noted resident prescribed Furosemide tab 20 mg PRN and Potassium Chloride 10 MEQ. These medications were not available in the facility on 8-12-25.
  3. On 8-12-25, during the medication pass observation with staff #6 on the safe, secure unit, resident #3’s physician’s order dated 7-17-25 and August 2025 MAR noted resident prescribed Midodrine 10 mg PRN. This medication was not available in the facility.
  4. Resident #4’s physician’s order dated 7-17-25 and August 2025 MAR noted resident prescribed Zofran 4mg PRN. This medication was not in the facility on 8-12-25.
  5. The facility’s policy and procedures, PP – 61050-Medication Management (VA), page 1 of 6, Ordering and Packaging, #1-d: “…the Branch will request a refill of all prescription medications managed by the Branch when the quantity of medications on hand is enough for seven days”.
  6. Staff #2 acknowledged the aforementioned residents’ PRN medications were not available in the facility.
Plan of correction
PLAN: Residents #1, #3, and #4 had their PRN medications replenished by the pharmacy. An audit of all resident PRN medications was conducted to assure that all residents had ordered PRN medications on the medication cart to be given, as needed. All Licensed Nurses and Medication Technicians were re-educated on the need to assure that all ordered PRN medications are on the medication cart and available to give, as ordered, when needed. Compliance will be monitored during weekly medication audits conducted on the 11 p.m. - 7 a.m. shifts by the RMAs. Monthly verification, utilizing the QuickMar PRN Medication List, will be completed by Nursing Leadership. Person Responsible: RMAs, Health & Wellness Dir., Health & Wellness Coord. Target Date of Completion: 9/15/2025 and ongoing
22VAC40-73-610-B
Based on document reviewed and staff interviewed, the facility failed to ensure the menu included all information.
Evidence
  1. On 8-12-25 the facility menu for August 2025, Week 4, did not include a listing of snacks provided.
  2. Staff #1 acknowledged the facility’s menu did not include snacks.
Plan of correction
PLAN: The Breadbasket Manager was re-educated on the requirements to have a list of available snacks posted with the menus on both the Assisted Living and Memory Care Activity Bulletin Boards. In additional, signage will be returned to both the Assisted Living Bistro and the Mary B's Breadbasket listing available snacks. This will be monitored by both the Happiness Coordinator, who maintains both Activity Bulletin Boards, and the E.D. Person Responsible: Breadbasket Manager, Happiness Coordinators, & the E.D. Target Date of Completion: 9/1/2025 and ongoing
22VAC40-73-100-C-2
Based on observation and staff interviewed, the facility failed to ensure blood glucose monitoring practice was conducted.
Evidence
  1. On 8-12-25 during the medication pass observation with staff #5 on the assisted living unit, the glucometer for resident #1’s glucometer was not labeled. Staff acknowledged the glucometer was not labeled.
  2. On the safe, secure unit (SCU)- Mary B’s unit, medication pass observation was conducted with staff #6. Residents #3 and #7’s glucometer were not labeled. Staff #6 acknowledged the glucometers were not labeled.
  3. The facility’s policies and procedures, PP – 10750- Infection Control: Communicable Diseases- (VA). Revised: 11-2024: Blood Glucose Monitoring Procedures, page 3 of 3, #1 noted: “Each piece of the individual’s equipment must me labeled with his or her name regardless of where the equipment is stored”.
  4. Staff #1 acknowledged facility staff did not follow facility’s policy for labeling of glucose monitoring supplies and equipment.
Plan of correction
PLAN: All Licensed Nurses and Medications Aides were educated to the need t label all part of the Glucometer with the resident's name and not just the storage pouch, which was labeled. Resident #1, #3 and #7 had each piece of equipment associated with their Glucometers labeled with his or her name. A complete audit was performed to assure that all residents with Glucometers have all parts labeled with his or her name. Compliance will be monitored during routine Weekly Medication Audits and Monthly by nursing leadership. Person Responsible: Health & Wellness Dirs./Coord., and RMAs Target Completion Date: 8/12/25 and ongoing
22VAC40-73-490-A
Based on observation and staff interviewed, the facility failed to ensure a health care oversight (HCO) report was provided to the licensing inspector.
Evidence
  1. On 8-12-25 the “What your inspector needs from you today” document was provided to the administrator. The Healthcare Oversight (HCO) document was not provided.
  2. On 8-13-25, the healthcare oversight was again requested but not provided during the two days of on-site inspection.
  3. The administrator completed the “What your inspector needs from you today” document but did not complete the section for the HCO review information.
Plan of correction
PLAN: Health Care Oversight to be completed by 9/15/25 If the person designated to complete our Health Care Oversight is physically unable or unavailable to complete this quarterly review, a back-up nurse within our organization will be asked to completed the review. A calendar reminder will be sent to those nurses designated to completed our Health Care Oversight quarterly and will include which residents are to be included in each review. Completion of this task will be monitored by the ED and Divisional Director of Health & Wellness Person Responsible: Health & Wellness Dir., Health and Wellness Coord., Exec. Dir., & Divisional Director of Health & Wellness Target Date of Completion: 9/15/2025 and ongoing
22VAC40-73-520-I
Based on documented reviewed, and staff interviewed, the facility failed to ensure the activity calendar included all information:
Evidence
  1. On 8-12-25, the posted activity calendar for the month of August 2025 did not include the length of time for the activity and it did not include the type of activity.
  2. Staff #1 acknowledged the activity calendar did not include all information.
Plan of correction
PLAN: The Happiness Coordinator was re-educated on the necessary components for both the Assisted Living and Memory Care Activity Calendars. There was also a review of the software used for both calendars, as a reference, so that they can be formatted, with all required information, as they were previously. a complete copy of the Standards for Licensed Assisted Living Facilities was also provided to the Happiness Coordinator. Moving forward, both calendars are to be completed between the 25th-27th of each month so that they can be reviewed by the E.D., or designee, prior to being professionally printed. Person Responsible: Happiness Coord., Happiness Asst., E.D., or the designee Target Date of Completion: 9/1/2025
22VAC40-73-990-C
Based on staff interviewed, the facility failed to ensure at lease once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years.
Evidence
  1. On 8-13-25, staff #1, did not provide documentation of all staff on each shift practicing resident emergency at least once every six months.
  2. Staff #1 acknowledged not having documentation of resident emergency for all staff on each shift.
Plan of correction
PLAN: A calendar reminder will be distributed to the HWD, HWC, & E/D. to that Resident Emergency Practice Drills are completed by each shift a minimum of every 6 months. The reminder will also include the type of resident emergency to be practiced. This practice drill will be documented and placed in the Survey Binder for easy access. A copy of the "What Your Inspector Needs From You Today" form will be updated every Friday and maintained in the Survey Binder. Person Responsible: Health & Wellness Dir., Health and Wellness Coord., Exec. Dir., or designee Target Date of Completion: 9/15/2025 and ongoing
22VAC40-73-640-A
Based on observation, document reviewed, and staff interviewed, the facility failed to ensure it disposed of medication as required.
Evidence
  1. On 8-12-25, during a medication pass and cart audit with staff #5, a packet of Melatonin for resident #2 was on the medication cart. A check of the resident’s August 2025 medication administration record (MAR) did not document Melatonin.
  2. A review of resident’s medication orders and MAR with staff #2, the resident’s Melatonin was discontinued on 6-23-25.
  3. The facility’s policy and procedures, PP – 61050- Medication Management (VA) page 2 of 6-a, Disposal, “all unused medications will be returned to the pharmacy or given to the RN Coordinator for destruction/disposal. The resident’s medication had not been removed for disposal.
Plan of correction
PLAN: Resident #2 D/C'd Melatonin was removed for the medication cart. All Licensed Nurses and Medication Technicians were re-educated on the need to remove all discontinued medications from the medication carts for either return to the pharmacy r given to the HWD of HWC for proper destruction. Compliance will be monitored during weekly medication audits conducted on the 11 p.m. - 7 a.m. shift by the RMAs. Monthly verification, utilizing the QuickMar D/C's Medication List, will be completed by Nursing Leadership. Person Responsible: RMAs, Health & Wellness Dir., Health $ Wellness Coord. Target Date of Completion: 9/15/2025 and ongoing
22VAC40-73-980-H
Based on observation and staff interviewed, the facility failed to ensure the availability of a 96-hour supply of emergency food and drinking water. At least 48 hours of the supply must be on site at any given time, of which the facility’s rotating stock may be used.
Evidence
  1. On 8-12-25, a check of the facility’s emergency supplies was conducted with staff #4. There were 21 boxes of 6 (1-gallon) water jugs. All of the boxes had a date of 3-31-25.
  2. Staff #4 acknowledged the water for the emergency supply was expired.
Plan of correction
PLAN: The Breadbasket Manager removed all expired water and replaced it with water, ordered from Sysco, that has an expiration date of 20 years from the date of packaging. This will be monitored annually during routine disaster readiness preparation. Person Responsible: Breadbasket Manager or designee Target Date of Completion: 9/3/2025 and ongoing
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the comprehensive individualized service plan (ISP) included all assessed needs.
Evidence
  1. On 8-12-25, resident #3’s uniformed assessment instrument dated 3-18-25 (signed by staff #1 on 3-22-5 and staff #2 on 3-21-25) noted bathing need as mechanical help/physical assistance (mh/pa). The ISP signed/dated by resident’s representative on 5-4-25 noted, resident performs bathing using shower chair and grab-bars. Dressing needs assessed as mh/pa, the ISP noted, assistance with dressing- mh/hh-pa. The ISP did not include what type of Based on record reviewed and staff interviewed, the facility failed to ensure the comprehensive individualized service plan (ISP) included all assessed needs. Evidence:
  2. On 8-12-25, resident #3’s uniformed assessment instrument dated 3-18-25 (signed by staff #1 on 3-22-5 and staff #2 on 3-21-25) noted bathing need as mechanical help/physical assistance (mh/pa). The ISP signed/dated by resident’s representative on 5-4-25 noted, resident performs bathing using shower chair and grab-bars. Dressing needs assessed as mh/pa, the ISP noted, assistance with dressing- mh/hh-pa. The ISP did not include what type of mechanical (mh) is use during bathing, staff are noted to standby to provide verbal cueing. Eating/feeding need assessed as human help/physical assistance (hh/pa), however, the ISP noted reminders or cueing to eat; did not include what physical assistance was needed.
  3. On 8-12-25, resident #4’s UAI dated 5-4-25 noted transfer need assessed as mechanical help/Supervision. The ISP dated by legal representative on 7-1-25 noted, resident, “transfers independently or using armchair or grabbers from seated position to standing”. There is no documentation for staff supervision. Walking, wheeling, stairclimbing and mobility assessed as mechanical help/physical assistance (mh/pa). The ISP not mobility and walking as human help/physical assistance- resident perform need, no documentation of BFM assisting with task. Eating/feeding assessed as human help/supervision; the ISP did not document what services were provided by BFM.
  4. Staff #2 acknowledged the aforementioned residents’ UAI and ISP did not match assessed with services care planned.
Plan of correction
PLAN: Resident #3 & resident #4 had their ISP's updated to include all of their assessed needs. Moving forward, all assessed needs will be compared to the ISP and audited by the Health and Wellness Coord. to assure that all assessed needs are reflected on the ISP. The audited and corrected (if needed) ISP will be uploaded and maintained in August Health. These will be spot checked during routine weekly eChart audits by the E.D. or designee. Person Responsible: Health & Wellness Dir., Health and Wellness Coord., and E.D./Designee Target Completion Date: 9/15/25 and ongoing
22VAC40-73-290-B
Based on observation and staff interviewed, the facility failed to ensure the name of the current on-site person in charge was posted.
Evidence
  1. On 8-12-25, the name of the current on-site person in charge was not posted. The posted document was dated 8-3-25 to 8-9-25. Staff #3 acknowledged the staff in charge posting was not current.
Plan of correction
PLAN: The Admin. Assist. is responsible for updating and posting the on-site person in charge weekly. Once that update is made, the posting will be shared with the E< HWD< HWC< and the FA. Should the Admin. Assist. not be in the Branch on the day it is to be posted, those listed above (in that order) will assume responsibility for posting it. A calendar reminder will be sent to those involved in this process This will be monitored for compliance every Monday. Person Responsible Admin. Assist., ED, HWD, HWC, and FA Target completion date: 8/12/2025 and ongoing
February 5, 2025Inspection6 violations
Inspection dates
02/05/2025,04/09/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 PROTECTION OF ADULTS AND REPORTING
Comments
Type of inspection: Monitoring An on-site unannounced monitoring inspection conducted on 2-5-25 (Ar. 09:55 a.m./ dep 2:45 p.m.). Day 4-9-25 (Ar. 10:32 a.m./dep 12:35 p.m.). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported complaint was received by VDSS Division of Licensing on 1-3-25 regarding allegations in the resident abuse, negative treatment by staff. Number of residents present at the facility at the beginning of the inspection: 57 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: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the (allegation(s)/self-report) 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 (Willie Barnes), Licensing Inspector at (757)-439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-380-B
Based on record reviewed, documents reviewed, and staff interviewed, the facility failed to ensure the resident’s personal and social data document was kept updated.
Evidence
  1. On 2-5-25, resident #1’s physical examination dated 11-25-24 noted resident allergic to Cephalexin. This allergy was also noted on the resident’s individualized service plan (ISP) dated 12-16-24, under the special care needs section. The resident’s personal and social data did not document Cephalexin as one of the resident’s allergies in the allergy section of the document. The personal and social data also noted the resident’s DNR (Do Not Resuscitate) was presented to the facility. The resident’s record did not have a signed/dated DNR from a physician. The resident’s ISP and Physician Orders dated 1-8-25 noted the resident as “Full Code”.
  2. Staff #1 acknowledged the resident’s personal and social data form was not kept updated.
Plan of correction
*August Health, our eChart software, assigns the Social Data Form to the family for completion, which increases the chances of that information not matching what the Provider documents on their forms. *These documents will be audited against each other and presented to the Provider and family for clarification. * All new admission charts will be audited weekly for accuracy and compliance of Admission Forms Responsible Person: Health & Wellness Dir., Health &Wellness Coord, Exec. Dir. & Admin Asst.
22VAC40-73-650-B
Based on document reviewed and staff interviewed, the facility failed to ensure the physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements included all required information.
Evidence
  1. On 2-5-25, resident #1’s physician order sheet (POS) dated 1-8-25 did not identify the diagnosis, condition, or specific indications for administering the following medications: (a) Century Mature Multivitamin, (b) DHEA 15mg, (c) Estradiol 0.7% gel, (d) Levothyroxine, (e) Memantine, (f) Methyl-Guard capsules, (g) Quetiapine, (h) Rivastigmine Patch, (i) Vitamin D plus K 5000 international unit (IU) and (j) Zinc Gluconate.
  2. Staff #1 acknowledged the resident’s POS did not include all required information, diagnosis or specific conditions for medications.
Plan of correction
*Resident #1 Physician Order Sheet was audited and updated to assure that each medication has either a diagnosis or specific condition for each medication. *All resident Physician Order Sheets to be audited and updated to assure that each medication has either a diagnosis or specific condition for each medication. *Resident Physician Order Sheets will be audited against new orders, during weekly medication audits, to assure that each medication has either a diagnosis or specific condition for each medication. Responsible Person: Health & Wellness Dir., Health &Wellness Coord, and Exec. Dir.
22VAC40-73-450-C
Based on record reviewed, document reviewed, and staff interviewed, the facility failed to ensure the resident’s individualized service plan (ISP) included all assessed needs.
Evidence
  1. On 2-5-25, resident #1’s uniformed assessment instrument (UAI) dated 12-9-24 and 12-15-24 noted bathing need assessed as human help/supervision. The ISP dated 12-16-24 noted resident, “…walk into the shower using grab bars and sit on…shower chair…BFM will wash body with washcloth and soap starting with upper body, lower body…BRM will wash perineal area, BRM will rinse...body starting with the upper body, following by the legs, front perineal area, and rectal area…BFM will pat dry…entire body from upper body to lower extremities. Dressing assessed as human help/supervision. The ISP noted, “BFM will assist…to decide what outfit is desired…then assist in applying to lower and upper extremities… BFM will…assist in removal of clothing and changing into pajamas…BFM will assist in dressing and undressing…” Toileting assessed as independent (no help). The ISP noted resident…transfer to and from commode with handrails, grab bars, walker and 1 BFM. Transferring assessed as independent (no help) …resident “can transfer from seated position to standing by using the arm of chair, 1 BFM, gait belt, walker or a wheelchair”. Walking, wheeling, stairclimbing and mobility assessed as no help. The ISP noted, resident is “able to walk with assisted device (walker), uses walker and handrails to climb stair”. Hearing needs noted reminders and set up. The record did not include the use hearing aids or another assistive device.
  2. The resident’s physical examination noted the resident to have physical therapy (PT) and occupational therapy (OT) services. The record included an initial evaluation and treatment for occupational services and physical therapy services and was electronically signed 1-12-25. “OT plan: resident to be seen 2 visits per week for a total of 90 days. Certification period…1-7-25 to 4-6-25. “PT plan: resident will be seen 3 visits per week for a total of 90 days. Frequency will be tapered to 2 visits per week by the end of the plan of care. Certification Period: 1-6-25 to 4-7-25”.
  3. Staff #1 acknowledged the resident’s assessed needs and ISP did not agree and therapy services needs were documented on the ISP.
Plan of correction
* August Health, our eChart software, populates information for the ISP from both the UAI and the Resident Assessment. Because those two documents don’t match, the information populated in the ISP does not always agree with the UAI. We are in dialogue with August Health to determine how this will be addressed in the software. In the meantime, these documents may need to be printed, manually corrected, and uploaded into the file. *Resident #1 UAI and ISP were audited and manually correct to accurately reflect the identified needs. *All new and updated UAIs presented in August Health for Exec. Dir. signature will be printed by the Exec. Dir. and audited against the ISP and updated, if needed, prior to being uploaded into the eChart. Responsible Person: Health & Wellness Dir., Health &Wellness Coord, and Exec. Dir.
22VAC40-73-310-H
Based on document reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions per 63.2-1805 D Code of Virginia for assisted living facilities.
Evidence
  1. On 2-5-25, resident #1’s physician’s orders (POS) dated 1-8-25 documented resident prescribed Quetiapine (Seroquel) psychotropic medication. The facility did not have a psychotropic treatment plan for this medication.
  2. Staff #1 acknowledged the resident did not have a treatment plan for the prescribed psychotropic medication.
Plan of correction
*Resident #1 Psychoactive Treatment Plan was obtained from her Provider who ordered it. *All resident records will to audited to assure that all with Psychoactive medication orders do have Psychoactive Treatment Plans on file. *Our Providers will be re-educated on the regulation regarding Psychoactive Treatment Plans and the need to provide one at the time they present us with an order for a Psychoactive medication, or we will not be able to administer the medication. Forms and instructions will again be placed in their binders. *Resident files will be audited against new orders, during weekly medication audits, to assure that all requiring Psychoactive Treatment Plans have them on file. Responsible Person: Health & Wellness Dir. & Health & Wellness Coord.
22VAC40-73-110-1
Based on document reviewed and staff interviewed, the facility failed to ensure that staff was considerate and respectful of the rights, dignity, and sensitivities of a person who is aged, infirm, or disabled.
Evidence
  1. On 2-5-25 and 4-9-25, the licensing inspector conducted an inspection regarding an emailed incident report from staff #1 on 1-3-25, informing the inspector that a resident in the safe, secure memory care unit was “alleged to have been physically abuse by a staff (CC #1) on 1-1-25 at approximately 8:15 p.m. Resident #1 was at the nurse’s station with a lamp, phone, basket and other items in resident’s arm. CC#1 tried to get the items from the resident, but the resident refused/resistant items being taken. Two witnesses (staff #3 and CC #2) reported and provided written statements that CC#1, “pushed resident down into a chair, squeezed resident’s hand, resident then hit CC#1. CC#1 then hit the resident…Resident #1 kicks CC#1 and CC#1 stomped on the resident’s right foot. Staff #3 and CC#2 goes to where the resident and CC#1 are on the memory care unit and intervenes in the situation. CC#1 then reaches around staff #3 and grab the back of resident #1’s neck. Staff #3 and CC#2 removes the resident from the situation and takes resident to resident’s bedroom. On the way to the bedroom CC#1, follows the resident and hit the resident on the buttocks.”
  2. On 4-9-25, staff #1 acknowledged staff CC#1 was not considerate of a resident on the safe, secure memory care unit who is aged and infirmed and did not treat the resident with dignity and respect.
Plan of correction
*CC#1 was suspended upon notification of the incident and terminated once the investigation was concluded. *Adult Protective Services, VA Board of Nursing, and DSS Licensing Inspector were notified of this incident by the Executive Director upon being informed of the incident and was fully cooperative and transparent with each agency. *In additional to the Annual Resident Rights and Abuse Reporting training, conducted by Bickford of Virginia Beach every August, a dedicated in-service on Resident Rights, Abuse, and Managing Stress/Self Control will be held for our staff in May and conducted by a professional within the scope of their practice. Responsible Person: Executive Director
22VAC40-73-320-A
Based on document reviewed and staff interviewed, the facility failed to ensure within 30 days preceding admission, the physical examination contain the required information.
Evidence
  1. On 2-5-25, resident #1’s physical examination for admission to the facility’s dated 11-25-24 noted the resident was ambulatory. The resident’s assessment of serious cognitive impairment dated 11-25-24 noted the resident was unable to recognize danger or protect his/her own safety and welfare. According to staff #1, the resident was admitted directly to the facility’s safe, secure unit upon admission to the facility.
  2. The resident’s risk assessment documenting the absence of tuberculosis (TB) in a communicable form was dated 10-29-24. Staff #1 confirmed the resident’s admit date was 12-10-24.
  3. Staff #1 acknowledged the facility’s physical examination was not correctly documented for a resident admitted to the safe, secure unit. The physical examination document noted the resident was ambulatory (physically and mentally capable of self-preservation). The TB risk assessment was more than 30 days.
Plan of correction
*All resident Physical Examination forms, received by the resident’s Provider, will be signed off on by Nursing Leadership, or the Exec. Dir. in their absence, stating that it is complete, filled in correctly, and compliant. When Providers present documentation that does not meet the Standards, it will be returned to them for correction stating that their patient cannot be admitted until all paperwork is complete and compliant. *All new admission charts will be audited weekly for accuracy and compliance of Admission Forms. Responsible Person: Health & Wellness Dir., Health &Wellness Coord, Exec. Dir. & Admin Asst.
February 5, 2025Complaint survey0 violations
Inspection dates
02/05/2025, 04/09/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND63.2 PROTECTION OF ADULTS AND REPORTING22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint An unannounced self-reported complaint inspection was conducted on 2-5-25 (2:50 p.m/ dep 3:25 p.m) 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 1-31-25 regarding allegations in the area of: buildings/grounds and infection control. Number of residents present at the facility at the beginning of the inspection: 57 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: N/A Number of staff records reviewed: N/A Number of interviews conducted with residents: Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: GI illness surveillance report, Infection Control policy PP-10750, Housekeeping/Laundry- PP-50850 Norovirus Biohazard Clean-up Vomitus, VDH Infection Prevention Quick Guide: Contact Precautions; Infection Prevention Quick Guide: Norovirus documents An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 11, 2024Inspection18 violations
Inspection dates
09/11/2024; 09/13/2024; 09/16/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal An on-site Renewal Inspection was conducted on 9-11-24 (Ar 07:20 am/Dep 18:10); 9-13-24 (09:30/ Dep 18:20) and 9-16-24 (Ar 09:20/Dep 18:25). Breakfast meal was observed on Day 1, emergency documents, fire drills, water temperature, first aid kit and emergency food and water items were completed. Resident and staff records reviewed, medication pass observation was also conducted. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-680-I
Based on document reviewed and staff interviewed, the facility failed to ensure the medication administration record (MAR) included all required information.
Evidence
  1. On 9-16-24, resident #2’s September 2024 MAR review with staff #1 did not include diagnosis, condition, or specific indication for Nuretin Omega 3 capsule.
  2. On 9-16-24, resident #5’s September 2024 MAR review with staff #1 did not include diagnosis, condition, or specific indication for Furosemide (Lasix).
  3. On 9-16-24, resident #6’s September 2024 MAR review with staff #1 did not include diagnosis, condition, or specific conditions for Calcium/Vitamin D, Probiotic capsule, Tramadol, Polyethene Glycerin Powder (Miralax), and Senna-Plus.
  4. On 9-16-24, resident #7’s September 2024 MAR review with staff #1 did not include diagnosis, condition, or specific indication for Amiodarone (Pacerone) and Guaifenesin.
  5. On 9-16-24, resident #8’s September 2024 MAR review with staff #1 did not include diagnosis, condition, or specific indication for Docusate Sodium Liquid (Colace) and Midorine (Proamatine).
  6. Staff #1 acknowledged the resident’s medication administration record did not include diagnosis, condition, or specific conditions for medication, supplement prescribed.
Plan of correction
*Resident #2 had the diagnosis added for the Nutretin Omega 3 capsule. *Resident #5 had the diagnosis added for the Lasix *Resident #6 had the diagnosis added for the Calcium/Vit D and the Polyethene Glycerin Powder. Resident #7 had the diagnosis added for the Amiodarone and Guaifenesin. Resident #8 had the diagnosis added for the Midorine. *All admission orders or new orders will also contain the diagnosis/condition/indication for use at the time the order is received and prior to sending to the pharmacy to be profiled. *HWD/HWC will monitor this weekly during their medication variance audits. Person Responsible: Health & Wellness Dir./Coord. Target Completion Date: 10/10/24
22VAC40-73-380-B
Based on record review and staff interviewed, the facility failed to ensure the personal and social data for a resident is in the resident’s record.
Evidence
  1. On 9-11-24 during record review with staff #2 and on 9-16-24 during record review with staff #1, resident #3’s record did not have documentation of a completion of a personal and social data document with the required information.
  2. Staff #2 acknowledged the resident’s personal and social data record was not in the resident’s record.
Plan of correction
*Resident #3 Face Sheet & Social Data forms were completed in their entirety to include information on vocation. *All resident files were audited to assure that each contained a Face Sheet & Social Data forms that include the vocation. Those with missing information will be resent to the POA, electronically in August Health, to be completed in its entirety. *All new admissions will have a eChart audit within 1 week of move in to ensure that these forms are complete with no missing information. Person Responsible: Exec. Dir., & Admin. Asst. Target Completion Date: 10/32/24
22VAC40-73-680-K
Based on observation, record reviewed, and staff interviewed, the facility failed to ensure PRN medications ordered shall include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24 -hour period, and directions as to what to do if symptoms persist.
Evidence
  1. On 9-11-24 during the medication pass observation with staff #4, resident #6’s September 2024 medication administration record (MAR) noted resident was prescribed Polyethene Glycerin Powder (Miralax), dissolve in 4-8 ounces water. The PRN order was not for an exact amount. The cup used to mix the powder and water was a 9 oz cup.
  2. Staff #1 and #2 acknowledged the PRN medication requirement was not conducted.
Plan of correction
*Resident #6 Polyethene Glycerin Powder order was clarified with the Provider with regards to the exact amount of water to be mixed in with the powder. *All new orders will be reviewed, prior to sending to the pharmacy, to assure that there are no ranges contained in any of the orders received by the Provider. *To assist the staff who administer this medication, a liquid measuring cup will be used to pour the exact amount of water ordered into the 9 oz cup used to administer the medication to the resident. *The RMAs will be educated on this new process by the HWD/HWC. Person Responsible: Health & Wellness Dir./Coord. Target Completion Date: 10/10/24
22VAC40-73-950-E
Based on documents reviewed and staff interviewed, the facility did not have documentation of the current semi-annual review on the facility’s emergency preparedness and response plan for all staff, residents, and volunteers.
Evidence
  1. On 9-11-24, the facility’s documentation of the semi-annual review of its emergency preparedness and response plan for all staff, residents, and volunteers was dated 2-28-24.
  2. Staff #1 acknowledged, the emergency preparedness and response plan were not conducted semi-annually as required.
Plan of correction
*The semi-annual review of the facility’s emergency preparedness and response plan will be completed will all staff, residents, and volunteers by the end of Oct. *The next semi-annual review will be scheduled on the Outlook calendar, at the first of the month, to be completed during that month. . *A sign-in form will be used to document those who participated Person Responsible: Exec. Dir., Maintenance Coord., & Happyness Coord. Target Completion Date: 10/31/24
22VAC40-73-410-A
Based on record reviewed and staff interviewed, the facility failed to ensure it obtained acknowledgement of having provided orientation to the resident or legal representative and kept a copy in the resident’s record.
Evidence
  1. On 9-11-24, during record with staff #1 and #2, resident #1’s record did not have documentation of having received orientation to the facility as a new resident.
  2. Staff #1 and #2 acknowledged the resident’s record did not have documentation of an orientation to the facility.
Plan of correction
*Resident #1 POA did not complete/return all of the eChart admission forms prior to move in. This was not discovered until after move in. This form was reviewed with him, and his mother, and signed/dated/uploaded. The form will be marked “completed as a part of a plan of correction – 9/27/24” *All pending admissions will have all Aug. Health move-in paperwork sent electronically. They will be instructed to read but not to complete until a week prior to the planned move in date. They will also be reminded that there can be “no blanks” in the paperwork. *Within 2 days of anticipated move in of new residents, outstanding Tasks in Aug. Health will be reviewed. The POA will be reminded that all outstanding tasks must be completed prior to move-in with some requiring review in person during the day of move-in. *New admission eCharts will be audited within 1 week following move in to assure that this form is complete and on file. Person Responsible: Exec. Dir., & Admin. Asst. Target Completion Date: 10/31/24
22VAC40-73-640-A
Based on record review and staff interviewed, the facility failed to ensure each resident’s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. On 9-16-24, during the record review with staff #1, resident #8’s physician’s order dated 8-2-24 noted resident prescribed Risperidone (Risperdal) twice a day, original date noted 7-3-24. This resident’s September 2024 medication administration record (MAR) did not include this medication. A check of the resident medication supply was conducted, the medication was not available in the facility for administration. Staff #1 acknowledged, resident #8’s medication ordered was not available for administration.
Plan of correction
*Resident #8 has a signed order in the Aug. Health eChart from prescriber, dated 7/3/24 for tapered dosing that reads as follows, “Resperidone 0.25mg po 9am & qhs x 4 d, then 0.5mg po qam & qhs x 4 d, then 0.5mg po qam & 1mg po qhs x 4 d, then 1mg po qam & qhs for depression/anxiety/paranoia” *Resident #8 also has a comprehensive Provider note, dated 7/3/24 in the Aug. Health eChart, explaining the process of tapering the doses between the Resperidone and the Zyprexa, and instructions regarding discontinuation. The medication was not on hand on 9/16/24 because it had already been discontinued. These documents were located on 10/3/24 on the eChart by Staff #2, who was not present for this portion of the inspection. *Additional instructions will be provided to staff responsible for scanning documents into the eChart to improve to process of locating scanned documents. *eCharts have a large number of scanned documents. When at all possible and available, the HWD/HWC will participate in locating the requested documents, as they are the most familiar with the medical contents of the medical records. When not available, more time will be needed for non-clinical staff to search for the requested clinical forms. Person Responsible: Health & Wellness Dir./Coord., Exec. Dir. & Admin. Asst. Target Completion Date: 10/3/2024
22VAC40-73-250-D
Based on document reviewed and staff interviewed, the facility failed to ensure a staff person on or within seven days prior to the first day of work at the facility submitted the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. On 9-13-24, during staff record reviews with staff #1, staff #6’s record did not have documentation of the absence of TB in a communicable form. The TB document from a local medical facility dated 8-10-23 documented the staff to “return to have Tb skin test read between 48-72 hours…return for reading between Saturday 08/12/23 at 05:15 PM and NO LATER THAN 04:45 PM on 08/13/23”. Staff’s date of hire noted as 8-11-23.
  3. Staff #1 and #6 acknowledged there was no documentation of the absence of TB within the required time prior to the first day of work.
Plan of correction
*Staff #6 had a negative TB Screening completed on 6/20/2024 *All existing staff from 6/20/2024 or prior have a negative annual TB screening on file, and all staff hired after 6/20/2024 have either a negative TB screening or PPD on file *Moving forward, unless contraindicated, all new hires will be screened for active TB by authorized licensed nurses at the Branch within but not later than 7 days of hire. Person Responsible: Exec. Dir., Health & Wellness Director/ Coordinator Target Completion Date: 10/4/24
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs, including reviews and updates.
Evidence
  1. On 9-11-24 during record review with staff #2, resident #2’s uniformed assessment instrument (UAI) dated 6-1-24 noted dressing as mechanical help (mh). The ISP noted staff was to provide resident with assistance undressing for bathing. The resident is assessed as being oriented. The ISP noted resident is unaware of place and time, forgets information…resident might plan activities but is unable to recall the time…redirection and orient as needed.
  2. On 9-11-24 during record review with staff #2, resident #3’s date on admit was noted 12-7-23 and the initial ISP was dated 3-11-24 by the developer, staff #2, and 6-10-24 by the legal representative and staff #1. The review date for the service plan was dated 06/2024. Resident #3’s record did not include an updated individualized service plan.
  3. 09-16-24 during record review with staff #2, resident #6, UAI dated 9-5-24 noted transfer need assessed as mechanical help/human help/physical assistance. The individual service plan noted resident transfers from seated position to standing by using the arms of chair or couch…resident transfers with mechanical assistance of chair arms and grab bars. The ISP noted resident occasionally wanders into different resident’s room…resident will be redirected and given task with an activity of interest. The resident’s UAI did not note this assessed need.
  4. Staff #1 acknowledged the residents’ record did not include all assessed needs.
Plan of correction
*Resident #2 will be reassessed in the areas of dressing and orientation to assure that his needs are accurate and match on the UAI and ISP. It will be reviewed with the POA/resident/signed/dated/uploaded into Aug. Health. *Resident #3 ISP and UAI updated to reflect resident’s current needs. It will be reviewed with the POA/resident/signed/dated/uploaded into Aug. Health. *Resident #6 ISP to be updated to reflect current needs with transfers and behaviors regarding wandering. UAI also to be updated to reflect those needs. It will be reviewed with the POA/resident/signed/dated/uploaded into Aug. Health. *These forms will be marked as “completed as a part of a plan of correction – 9/27/24” *A 2 person cross-check between the UAI & ISP will be completed, for accuracy. Any error noted will be corrected prior to the resident/POA receiving it for signature. Person Responsible: Health & Wellness Dir./Coord, Exec. Dir. & Admin Asst. Target Completion Date: 10/31/24
22VAC40-73-650-B
Based on document reviewed and staff interviewed, the facility failed to ensure the physician or other prescriber’s orders included all required information.
Evidence
  1. On 9-16-24, resident #2’s physician’s orders and medication administration record (MAR) review was conducted with staff #1. Resident #2’s physician’s orders dated 8-9-24 did not include diagnosis, condition, or specific indication for Nuretin Omega 3 capsule being administered.
  2. Resident #5’s Furosemide (Lasix) noted on the physician’s order dated 8-19-24 did not include a diagnosis, condition, or specific indication for the prescribed medication.
  3. Resident #6’s Calcium/Vitamin D, Probiotic capsule, and Polyethene Glycerin Powder (Miralax) noted on the physician’s order dated 8-9-24 did not include a diagnosis, condition, or specific indication for the prescribed medications.
  4. Resident #7’s Amiodarone (Pacerone) and Guaifenesin noted on the physician’s order dated 8-9-24 did not include diagnosis, condition, or specific indication for the prescribed medications.
  5. Resident #8’s Midorine noted on the physician’s order dated 8-2-24 did not include diagnosis, condition, or specific indication for the prescribed medication.
  6. Staff #1 acknowledged the residents’ records did not include the diagnosis for prescribed medications noted on the physician’s order and medication administration records.
Plan of correction
*Resident #2 had the diagnosis added for the Nutretin Omega 3 capsule. *Resident #5 had the diagnosis added for the Lasix *Resident #6 had the diagnosis added for the Calcium/Vit D and the Polyethene Glycerin Powder. Resident #7 had the diagnosis added for the Amiodarone and Guaifenesin. Resident #8 had the diagnosis added for the Midorine. *All admission orders or new orders will also contain the diagnosis/condition/indication for use at the time the order is received and prior to sending to the pharmacy to be profiled. *HWD/HWC will monitor this weekly during their medication variance audits. Person Responsible:Health & Wellness Dir./Coord Target Completion Date: 10/10/24
22VAC40-73-310-B
Based on record reviewed and staff interviewed, the facility failed to ensure a documented interview between the administrator or a designee responsible for admission and retention decisions, the individual, and the legal representative, if any, was completed.
Evidence
  1. On 9-11-24, record review with staff #1 and #2, resident #1 (date of admit 8-27-24) and #3 (date of admit 12-7-23) record did not have documentation of an interview.
  2. Staff #1 and #2 acknowledged the residents record did not have documentation of an interview.
Plan of correction
*Residents #1 and #3 had their Interview Date added to their Mental Health Screening Form. That date will be the date of the pre-admission assessment. *All remaining resident records will be audited to assure that there *Residents #1 and #3 had their Interview Date added to their Mental Health Screening Form. That date will be the date of the pre-admission assessment. *All remaining resident records will be audited to assure that there is a Mental Health Screening Form and that it contains the date of the Interview. *New admission eCharts will be audited within 1 week to assure that this form is on file and contains that date. Person Responsible: Health & Wellness Dir./Coord., Exec. Dir. or Designee Target Completion Date: 10/10/24
22VAC40-73-310-H
Based on records reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with a prohibitive condition or care needs.
Evidence
  1. On 9-11-24, during medication pass observation with staff #4, resident #4 was administered Escitalopram (Lexapro). The resident’s September 2024 medication administration record (MAR) and physician order dated 8-1-2024 noted Lexapro. The record did not include a psychotropic treatment plan for this medication.
  2. On 9-11-24, during medication pass observation with staff #4, resident #6 was administered Trazadone. The resident’s September 2024 MAR and physician’s orders dated 8-9-24 noted resident prescribed Lorazepam (Ativan), Paroxetine (Paxil) and Quetiapine (Seroquel) and Trazadone. The record did not include a psychotropic treatment plan for Paroxetine and Lorazepam.
  3. Resident #7 was administered Buspirone (Buspar) during medication pass observation with staff #6. The resident’s September 2024 MAR and physician’s orders dated 8-9-24 noted resident prescribed Quetiapine (Seroquel), Alprazolam (Xanax)and Buspirone. The resident’s record did not include a psychotropic treatment plan for these medications.
  4. Resident #8’s was administered Trazadone and Quetiapine (Seroquel) during the medication pass observation with staff #6. The resident’s September 2024 MAR and physician’s orders dated 8-2-24 noted resident prescribed Buspirone (Buspar), Mirtazapine (Remeron), Quetiapine, Risperidone (Risperdal), Sertraline (Zoloft), Trazadone and Lorazepam (Ativan). The resident’s record did not include a psychotropic treatment plan for these medications.
  5. On 9-16-24, during medication record review with staff #1, resident #3’s September 2024 MAR noted resident administered Sertraline (Zoloft). The resident’s physician’s order dated 8-9-24 noted resident prescribed Sertraline. The resident record did not include a psychotropic treatment plan for this medication.
  6. Staff #1 acknowledged the residents record did not include a psychotropic treatment for psychotropic mediations as required.
Plan of correction
*Residents #4, #6, and #7 now have Psychoactive Treatment Plans for the medications identified. *A list of all residents with orders for Psychoactive medications will have their eCharts audited to assure that there is a treatment plan for each medication. *Each Provider will receive a blank Psychoactive Treatment Plan form with each new prescription received. *All eCharts will be audited weekly during the Med Variance Audits for compliance Person Responsible: Health & Wellness Dir./Coord. Target Completion Date: 10/10/24
22VAC40-73-260-C
Based on document reviewed and staff interviewed, the facility failed to ensure the listing of all staff who have certification in first aid or cardiopulmonary resuscitation (CPR) was kept up to date.
Evidence
  1. On 9-13-24, the inspector inquired of staff #5 where the First Aid/CPR listing was posted. Staff point to the wall across from the medication room near the nurse’s station on the assisted living unit of the building. Staff #7 came to the area at the same time and ask if the inspector needed help. The inspector pointed to the FA/CPR listing and showed both staff members, the listing which was updated by staff #7 on 9-10-24. The posted list included names of staff with dates that are were not current. Staff #8’s card expired 7-24-24, staff #9’s card expired 9-7-24 and staff #10’s card expired 3-7-24.
  2. Staff # 5 and #7 acknowledged the First Aid/CPR listing was not kept up to date.
Plan of correction
*The First Aid/CPR Listing was updated on 9/13/24 to reflect only staff members with current certification, to include staff member #10 who had just provided current certification on 9/13/24. *All staff, at the time of hire, who do not have current CPR will be educated on the need to obtain it within 60 days. Those who are Direct Care Staff will also be required to either have or obtain First Aid within 60 days of hire. *The list will be updated at the beginning of each month, and those with certifications that expire at the end of that month will be notified of the need to renew before expiration. Person Responsible: Executive Dir. & Admin. Asst. Target Completion Date: 9/13/24 Ongoing
22VAC40-73-970-E
Based on document reviewed and staff interviewed, the facility failed to ensure the fire and emergency evacuation drills included all the required information .
Evidence
  1. On 9-11-24, a review of the facility’s fire and emergency evacuation drills dated 6-1-24 and 7-18-24 did not include the weather conditions.
  2. Staff #1 acknowledged the fire and emergency documents did not include all required information.
Plan of correction
*The Maint. Coord. researched the weather conditions for the dates of 6/1/24 & 7/18/24 and added it to the Fire Drill Report. *The Maint. Coord will take the form used to document the Fire Drills and “highlight” the directions where it says to document the current weather conditions at the time of the drill, as a reminder not to omit this information from the report. *A copy of all drills conducted by the Maint. Coord. will be provided to the Exec. Dir. for review and to be added to the Survey Binder. Person Responsible: Maintenance Coord. & Exec. Dir. Target Completion Date: 10/10/24
22VAC40-73-680-M
Based on observation, record reviewed, and staff interviewed, the facility failed to ensure medications ordered for PRN (as needed) administration was available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. On 9-11-24, following medication pass observation with staff #3, the prescribed PRNs noted on resident #2’s physician’s orders dated 8-9-24 and September 2024 medication administration record (MAR) were not available. Tylenol, Albuterol inhaler and Diclofenac gel were not available in the facility.
  2. On 9-11-24, following medication pass observation with staff #4, the prescribed PRN noted on resident #6’s physician’s orders dated 8-9-24 and September 2024 MAR were not available. Trazadone, Tylenol, Melatonin and Senna-Plus were not available in the facility.
  3. On 9-11-24, following medication pass observation with staff #4, the prescribed PRN noted on the resident #8’s physician’s orders 8-2-24 and September 2024 MAR were not available. Albuterol (Pro Air HFA), Tylenol and Senna Plus were not available in the facility.
  4. Staff #1 and #2 acknowledged the residents’ PRN medications ordered were not available in the facility.
Plan of correction
*Resident #2 had their Tylenol, Albuterol, and Diclofenac gel were discharged by the Provider. *Resident #4 had their Trazadone and Melatonin on the cart at the time of the cart inspection. The Tylenol and Senna Plus were re-ordered. *Resident #8 had their Albuterol, Tylenol, and Senna Plus on the med cart at the time of the inspection. They were filled prior to the inspection. *HWD/HWC to print a list of PRNs weekly and provide it to the RMAs to audit against the medications we have on hand to assure that all PRNs are available to be given, if needed. *HWD/HWC to review this at the time of their weekly medication variance audits. Person Responsible: Health & Wellness Dir./Coord. & RMAs Target Completion Date: 10/10/24
22VAC40-73-550-G
Based on record reviewed and staff interviewed, the facility failed to ensure the rights and responsibilities of residents were reviewed with residents.
Evidence
  1. On 9-11-24 during record review with staff #2 and on 9-16-24 with staff #1, resident #2’s record did not have documentation of an annual review of the rights and responsibilities of residents in an assisted living facility. The resident’s date of admit was noted as 12-23-22.
  2. On 9-16-24 during record review with staff #1, resident #8’s record did not have documentation of an annual review of the rights and responsibilities of residents in an assisted living
  3. Staff #1 acknowledged the resident’s record did not have documentation of the annual rights review.
Plan of correction
*Needed corrections to the Resident Rights form was communicated to August Health. *Resident #2 completed an annual Resident Right’s Review on 10/4/2024. The form was uploaded into Aug. Health. *All other residents will complete an annual Resident Rights review in Aug. Health once the form has been corrected. Otherwise, it will be done on paper and uploaded. *October will be designated and scheduled as the month for the annual Resident Rights Review. Person Responsible: Exec. Dir., Happyness Coord. & Admin. Asst. Target Completion Date: 10/31/24
22VAC40-73-325-B
Based on record review and staff interviewed, the facility failed to ensure the resident’s record include documentation of a fall risk assessment.
Evidence
  1. On 9-11-24, during record review with staff #2, resident #2’s record did not have documentation of an annual fall risk assessment. A review of resident’s clinician notes dated 8-17-24 at 08:06 AM, the resident’s record noted a fall with skin tear to the left arm. The record did not have documentation of an assessment following a fall.
  2. On 9-11-24, during record review with staff #2, resident #3’s record did not have documentation of an initial fall risk assessment. Resident #3 assessed at the assisted living level of care and the resident’s date of admit noted as 12-7-23. The staff presented an assessment that was dated 9-11-24.
  3. On 9-16-24, during record review with staff #1, resident #7’s fall risk assessment provided was dated 3-25-24. The resident’s clinical notes documented falls on 4-13-24 at 05:05 AM…resident observed walking in the courtyard. All of a sudden resident was observed on the ground lying on back by the table and chairs…no injuries noted. Clinical notes documented on 4-11-24 at 09:00 AM, unwitnessed fall…resident found on floor in room next to sink on floor…resident complained of right shoulder and right hip pain and chest pain. The resident was sent out to ER. Clinical notes documented on 4-4-24 at 12:30 AM, resident was heard yelling for help by another resident; resident observed on the floor lying on left side behind the door…right side of resident’s head appeared to be swollen and sore when touched…resident sent out to the ER. The fall risk assessment provided was dated 3-25-24. There were no assessments for the falls noted in the record.
  4. Staff acknowledged that the risk assessment for the residents were not completed as required.
Plan of correction
*Residents #2, #3, & #7 each have current Fall Risk Assessments in their eCharts. *All eCharts for Assisted Living residents will be audited to assure that they contain a current Fall Risk Assessment/Post Fall Risk Assessment. Those without will be assessed and the form marked as “completed as a part of a plan of correction – 9/27/24” * New admission eCharts for Assisted Living residents will be audited within 1 week to assure that this form is completed and on file. Person Responsible: Health & Wellness Dir./ Coord., Exec. Dir., Admin. Asst. Target Completion Date: 10/31/24
22VAC40-73-990-C
Based on document reviewed and staff interviewed, the facility failed to ensure at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained.
Evidence
  1. On 9-11-24, a review of staff’s participation in an exercise in which the procedures for resident emergencies were conducted, dated 6-21-24 (missing person), did not include all staff on each shift.
  2. Staff #1 acknowledged; the resident emergency practice conducted on 6-21-24 did not include all staff on each shift.
Plan of correction
*A resident emergency practice drill will be conducted before the end of Oct., and that drill will be practiced on all 3 shifts. *The next semi-annual review will be scheduled on the Outlook calendar, at the first of the month, to be completed during that month, to assure that it is completed every 6 months. *A sign-in form will be used to document those who participated on all 3 shifts. Person Responsible: Exec. Dir., Health & Wellness Dir./Coord. Target Completion Date: 10/31/24
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure a resident individualized service plan (ISP) was completed.
Evidence
  1. On 9-11-24 during record review with staff #2, resident #1’s record did not have documentation of a preliminary plan of care or a comprehensive plan of care with resident’s assessed needs prior to and following admission to the facility The resident’s date of admission was noted as 8-26-24.
  2. Staff #2 acknowledged resident #1 did not have an Individualized Service Plan for resident #1.
Plan of correction
*Resident #1 to have her comprehensive ISP completed, reviewed, signed, and uploaded by 10/10/24 and marked as “completed as a part of a plan of correction – 9/27/24” *All other resident records will be audited to assure that each has an initial ISP that has been reviewed, signed, and uploaded into Aug. Health *All future admissions will be assessed prior to move in. That assessment will be used to complete the initial ISP that will be reviewed with the POA and resident (when appropriate) on the day of move in. *New admission eCharts will be audited within 1 week of move-in to assure that the initial ISP has been reviewed, signed, dated and uploaded into the eChart. Person Responsible: Health & Wellness Dir./Coord, Exec. Dir. & Admin. Asst. Target Completion Date: 10/31/24
July 23, 2024Complaint survey7 violations
Inspection dates
07/23/2024;08/16/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint An on-site complaint inspection conducted on 7-23-24 (Ar 10:20 a.m./ Dep 18:38 p.m.) and 8-16-24 (Ar 10:25 a.m./Dep 14:00 p.m.) 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 7-14-24 regarding allegations in the area of resident care and related services Number of residents present at the facility at the beginning of the inspection: 54 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: 11 Observations by licensing inspector: observed bruising on resident’s upper chest/neck area Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation 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 Willie Barnes, Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-460-E
Based on record reviewed and staff interviewed, the facility failed to regularly observe each resident for changes in physical, mental, emotional, and social functioning.
Evidence
  1. On 7-23-24 during a complaint inspection received regarding bruises to anterior chest, neck and forearms of resident #1, the inspector observed bruising to the resident neck area, no other area was checked to avoid resident becoming agitated.
  2. The bruising was in the same area of the body reported in the complaint and in the photos received. The photos reviewed showed the areas of bruising to resident’s neck area, back area, right forearm and left wrist area.
  3. Interview with C-1, resident #1 was observed in bed with visible bruising to the chest area, neck, forearm on the morning of July 9, 2024. There was no documentation in the resident’s record of these bruising prior to July 9, 2024.
  4. Staff #1 sent an incident report on July 9, 2024, reporting staff’s observance of bruising near resident #1’s collar bone and down to resident’s upper rib cage. Also noted were some isolated round purple bruises on resident’s back. The resident’s report from the Emergency Room visit noted that resident #1’s was diagnoses with a closed displaced fracture of shaft of the right clavicle.
  5. The resident’s individualized service plan dated 6-18-24 noted staff was instructed to physically assist resident with bathing by washing resident’s upper and lower body. Staff was also instructed to physically assist resident with dressing and undressing clothing and assisting with changing into pajamas at 9:30 p.m.
  6. There was no documentation in the resident’s record prior to July 9, 2024, date of any injuries to the resident.
  7. Staff #1 acknowledged the resident’s body had visible bruising on the neck, back and arm areas of the body on the morning of July 9, 2024. Staff also acknowledged the resident’s record did not have documentation of these bruising.
Plan of correction
HWD, at that time, was educated on the importance of assuring that there is no inaccurate carry-over from one UAI/ISP to the next, as that information was no longer current and over presented the assistance needed by resident #1 at the time of that UAI/ISP completion. HWD, at that time, also encouraged to include the direct care staff's input when documenting a resident's current ADL/IADL needs on the UAI/ISP Resident #1 relocated to Memory Care. She has been reassessed, utilizing the UAI/ISP, to include the areas of assistance needed with bathing. I was reviewed with the POA/resident/signed/dated/uploaded into Aug. Health. Responsible Person: Health & Wellness Dir./Coord, Exec. Dir. & Admin Asst.
22VAC40-73-650-F
Based on record reviewed and staff interviewed, the facility failed to ensure when a resident is admitted to a hospital for treatment or any condition, the facility shall obtain new orders for all medications and treatments prior to or at the time of the residents 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 new orders.
Evidence
  1. On 7-23-24, resident #1’s discharge summary noted resident was admitted to a local hospital 6-21-24 to 6-27-24. The resident’s record did not have documentation of primary physician contact and made aware of all medication’s orders. The resident’s clinical notes documented primary physician and power of attorney notified on 6-21-24 when resident was transferred from the facility to the Emergency room, but no documentation of return to the facility and communication with physician.
  2. Staff #2 stated the resident’s primary came to the facility on 7-2-24 and reviewed the resident's discharge summary, however there was no documentation in the resident’s record.
Plan of correction
Resident #1 has not been hospitalized or sent to the ER during this timeframe. Notation of a resident's return from the hospital will be reflected in the resident's eChart. All re-admission orders from the hospital will be reviewed by the HWD and then forwarded to the PCP to review and approve, as evidenced by their notation/signature/initials/etc. HWD/HWC will then forward those verified orders/discharge summaries to be scanned and uploaded into the eChart. Responsible Person: Health & Wellness Dir./Coord, RMA/CNA/PCA
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure that the resident’s individualized service plan (ISP) reflected resident’s assessed needs.
Evidence
  1. On 7-23-24, resident #1’s uniformed assessment instrument (UAI) dated 6-10-24 noted dressing need assessed as mechanical help. The individualized service plan (ISP) dated 6-18-24 noted mechanical help only. It also noted staff to assist resident with changing into pajamas at night and staff to assist resident with morning dressing and bedtime undressing and provide assistance as needed. The care plan did not include what mechanical help was needed. Eating need assessed 6-10-24 as no help needed. The ISP dated 6-18-24 noted resident required cueing to eat. Resident’s behavior assessed as appropriate, the ISP noted resident is disoriented to place and time and has confusion, wanders and “exhibit a range of behavioral and psychological symptoms, such as agitation, depression, and hallucinations”. Resident also prescribed psychotropic medications and psychological services from a local agency. The ISP noted the resident “has no problem with wandering or elopement concerns.” The ISP noted, under title “Disposition and Behaviors”, no support or assistance. Resident assessed as incontinent of bladder/bowel, less than weekly, the ISP did not indicate what care needs to be completed. Resident #1’s UAI dated 7-16-24 noted dressing need assessed as mechanical help. The ISP dated 7-19-23 noted assistance with dressing, mechanical help only. The ISP also noted “full assistance with dressing, assistance due to dressing and undressing throughout the day, assistance with morning dressing. The mechanical device needed was not noted. Toileting need assessed as mechanical help only. Bowel and bladder need assessed as incontinent weekly or more. Toileting noted on ISP as mechanical help only. Full assistance with all aspects of bathroom activities and hygiene. Assistance with bowel continence - Incontinent | Weekly or More. Assistance with bladder continence - Incontinent | Weekly or more. The care plan did not note if use of incontinent products were needed. Staff #2 stated during interview on 7-23-24, resident would soil undergarments and wash items in bathroom and hang to dry. Behavior on UAI dated 7-16-24 assessed as appropriate, the ISP dated 7-19-24 noted the same behaviors, as the 6-18-24 ISP. The plan is noted no disruptive behavior as previously noted on 6-18-24 service plan. Resident continues to receive psychological care from an outside agency as of 8-16-24. This need is not on the ISP dated 6-18-24 and 7-19-24. Psychological visits in record dated 6-19-24 and 7-17-24 noted psychiatric follow-up evaluation. Resident’s psychiatric notes documented resident’s allergy to Ambien, Acetazolamide, Erythromycin and Sulfa Antibiotics. Resident’s physician order sheet (POS) dated 4-8-24 and May, June and July 2024 medication administration record (MARs) noted allergy to Sulfa Antibiotics. These allergies were not addressed on the resident’s ISPs.
  2. Staff #1 and #2 acknowledged the resident’s ISPs dated 6-18-24 an 7-19-24 did not include all assessed needs. On 8-1-24 during preliminary conference, Staff #1 stated resident was mainly independent and that the facility over assessed the resident.
Plan of correction
Resident #1 relocated to Memory Care. She has been reassessed, to include the areas of assistance with dressing, types of mechanical help needed, assistance needed with eating, incontinence, drug allergies, behaviors, and level of orientation to assure that those needs are accurate and match on the UAI and ISP. It was reviewed with the POA/resident/signed/dated/uploaded into Aug. Health. Responsible Person: Health & Wellness Dir./Coord, Exec. Dir. & Admin Asst.
22VAC40-73-640-A
Based on document reviewed and staff interviewed, the facility failed to ensure that each resident’s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. On 7-23-24, resident #1’s May 2024 medication administration record (MAR) noted resident’s Metoprolol Tartate 9 a.m. medication was not available on 5-16 thru 5-18-24. The MAR noted “given when pharmacy delivered supply”.
  2. Resident’s June 2024 MAR noted, resident’s Ramelton 8 mg tablet, 6-27-24 is blank and 6-30-24 noted pharmacy. Risperidone 0.25mg tablet 6-28-24 (8 a.m. is blank); 6-29-24 (8 a.m. and 5 p.m.) noted given when pharmacy delivered supply.
  3. Resident’s July 2024 MAR noted, resident’s Diclofenac Sodium 1% gel prescribed for 4 times a day was not available on 7-11-24 (8 a.m./ 12 p.m./8 p.m.); document noted given when pharmacy delivered supply. Lidocaine (SALONPAS) apply every morning (8 a.m.) and remove after 12 hours (8 p.m.) not available on 7-11-24, given when pharmacy delivered supply.
  4. The staff acknowledged; the resident’s medications/supplement was not available for administration.
Plan of correction
HWD to conduct a current and complete audit of all of resident #1 medications to assure that all routine and PRN medications are available to administer, as ordered. HWD to review medication variance audits weekly to assure that all medications are documented as being given, as ordered. When there is a deviance in this area, the PCP is to be notified. Person Responsible: Health & Wellness Dir./Coord,
22VAC40-73-325-B
Based on documents reviewed and staff interviewed, the facility failed to document the analysis of the circumstances of a fall and the interventions that were initiated to prevent or reduce risk of subsequent falls.
Evidence
  1. On 7-23-24, resident #1’s record reviewed with staff #2, noted fall assessments were dated 5-6-22, with a score of 12; and 6-18-24 with a score of 14. According to staff #2, the resident did not have any documented falls.
  2. On 7-9-24, the email and incident report from staff #1 regarding resident #1’s bruising’s on body noted the resident’s “most recent fall that the staff are aware of was on 7/6/24 @10:50 p.m. and again on that same 11-7 shift on 7/7/24 @ 6:00 a.m.”. Interview with staff #11 and resident’s clinical notes documented by the same staff noted, resident was in bedroom screaming and on the floor. Staff #11 stated during phone interview on 7-29-24, observing resident sitting “Indian style” on the floor in the room. Staff stated not documenting the fall on 7-6-24 and stated reporting the situation to the supervisor, staff #2.
  3. On 8-16-24, the facility’s fall policy was requested from staff #1. The “FALLS” document was dated “Revised 4-2014”. No updated policy provided.
  4. Staff #11 acknowledged not documenting the two times resident was observed on the floor.
Plan of correction
Staff educated on the importance of thorough documentation of behavioral events. When staff #6 was interviewed by the HWD, she reported seeing resident #1 deliberately "plop" herself down on the floor on 7/7/24. She was in the hallway, and the door was cracked open. The importance of full and complete details was emphasized. Resident #1 to have a Fall Risk Assessment, with interventions, completed following each fall. All eCharts for Assisted Living residents will be audited to assure that they contain a current Fall Risk Assessment/Post Fall Risk Assessment. Those without will be assessed and the form marked as "completed as a part of the plan of correction - 1/15/2025: New admission eCharts for Assisted Living residents will be audited within 10 days to assure that this form is completed and on file. Person Responsible: Health & Wellness Dir/Coord, Exec. Dir. & Admin Asst.
22VAC40-73-680-I
Based on record reviewed and staff interviewed, the facility failed to ensure that the medication administration record (MAR) included all required information.
Evidence
  1. On 07-23-24, resident #1’s May, June and July 2024 medication administration record (MARs) did not include the diagnosis, condition or specific indications for administering the following drug or supplement: May, June and July MAR (a) Buspirone 10 mg tablet; (b) Combigan 0.2-0-5% eye solution and (c) Trazadone 50 mg tablet. June’s MAR did not include diagnosis for the previously mentioned drugs and new medication; Ramelton 8 mg tablet and Risperidone 0.25 mg tablet (seven days, twice a day). July’s MAR did not include diagnosis for medications noted for MAY’s MAR and June’s MAR and new medications: Cephalexin 500 mg capsule, Risperidone 0.25mg tablet/bedtime seven days.
  2. Staff acknowledged the resident’s MARs did not include diagnosis, condition or specific indications for administering drug or supplement.
Plan of correction
Resident #1 has not been hospitalized or sent to the ER during this timeframe. Moving forward, all re-admission orders from the hospital will be reviewed by the HWD and then forwarded to the PCP to review and approve, as evidenced by their notation/signature/initials/etc. HWD/HWC will then forward those verified orders/discharge summaries to be scanned and uploaded into the eChart. Responsible Person: Health & Wellness Dir./Coord
22VAC40-73-650-B
Based on document reviewed and staff interviewed, the facility failed to ensure that the physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often the medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug.
Evidence
  1. On 7-23-24, resident #1’s physician’s order dated 4-8-24 did not include the diagnosis, condition, or specific indications for the following drug and/or supplement: (a) Combigan 0.2-0.5% eye solution and (b) Buspirone 10 mg tablet. Physician’s orders dated 7-9-24 did not include diagnosis for (a) Salonpas 4% patch, (b) Cephalexin 500mg capsule, (c) Diclofenac Sodium 1% topical gel and (d) Tramadol 50 mg tablet.
  2. Staff acknowledged the resident’s physician’s orders did not have the diagnosis, condition, or specific indications for the drugs/supplement.
Plan of correction
Resident #1 had her Physician's Order Sheet audited by the HWD to assure that all current medications include the diagnosis, condition, or specific indications for administering medications or supplements. Any new orders will also be reviewed and initialed by the HWD/HWC to assure that they contain the diagnosis, condition, or specific indication for use at the time the order is received and prior to sending to the pharmacy to be profiled. HWD/HWC will monitor this weekly during their medication variance audits. Responsible Person: Health & Wellness Dir./Coord,
September 25, 2023Inspection19 violations
Inspection dates
09/25/2023,10/05/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal An on-site renewal inspection was conducted on 9-25-23. Ar (07:55 a.m./Dep 18:30 p.m.) The facility census was 61. A tour of the facility was conducted, medication pass observed, dinner observed, staff and resident interviews and records reviewed, emergency preparedness reviewed. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757)-439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-680-I
Based on observation, document reviewed, and staff interviewed, the facility failed to ensure the facility’s medication administration record (MAR) included all required information.
Evidence
  1. On 9-25-23 during the medication pass observation with staff #3, resident #4’s Bumex did not include the diagnosis, condition, or specific indications for administering the drug or supplement.
  2. Staff #3 acknowledged the resident’s September 2023 MAR did not include the diagnosis for Bumex.
Plan of correction
*Resident #4 had the Physician Order Sheet (POS) and MAR updated to reflect the diagnosis, condition, or specific indications for administering the medication. *A 100% audit of all Physician Order Sheets and MARs to be conducted to assure that all medications ordered have an a diagnosis. *Health & Wellness Dir. and/or Coord. to review all POS/MAR, at the time of move in and when new orders are received, to assure that a diagnosis is included for each medication. *This will be audited monthly when the Physician Order Sheets are printed and signed. Person Responsible: Health & Wellness Dir., Coord, or Designee. Target Date of Completion: 10/25/2023 & Ongoing
22VAC40-73-980-H
Based on observation and staff interviewed the facility failed to ensure the availability of a 96-hour supply or emergency food and drinking water. At least 48 hours of the supply must be on site at any given time, of which the facility’s rotating stock may be used.
Evidence
  1. On 9-25-23 during a tour of the facility, when asked about the facility’s emergency supply, staff #5 stated the facility did not have any water and the food supply was what was currently in the facility. The facility was expecting a food order from its local supplier, but no water was part of the food order.
  2. Staff #1 acknowledged the facility did not have at least 48 hours of emergency supply on site on 9-25-23.
Plan of correction
*Our emergency water and food supplies were ordered from Sysco and did arrive on 9/27/23 along with our routine weekly food order. *The kitchen manager will write the expiration date in a visible location on each of the boxes of water and will monitor the expiration date to assure that our replacement inventory is ordered and arrives before the water on hand expires. *The Kitchen Manager was also instructed to store her non-perishable food items, to be used with the emergency menu, in a designated area in the dry storage room along with a copy of the corresponding menu so that the items can be easily inventoried and re-ordered, as needed. *This will be monitored quarterly during our Registered Dietician visits and annually during our Core-Checks. Person responsible: Kitchen Manager, Exec. Dir., and Registered Dietician
22VAC40-73-980-A
Based on observation and staff interviewed, the facility failed to ensure the first aid kits contained all required items.
Evidence
  1. On 9-25-23 during a check of the first aid kit for the nursing station with staff #2, the antiseptic ointment was dated 08/2021. The first aid kit for the vehicle used to transport resident, antiseptic ointment was dated 02/2023.
  2. Staff #2 acknowledged the first aid kit for the nursing station and vehicle’s antiseptic ointment were expired.
Plan of correction
*The Antiseptic Ointment was replaced in both the Assisted Living and Van First Aid Kits. *Bickford of Virginia Beach has modified their list of contents in their First Aid Kits to match the requirements of DSS to make the monthly inspection process more seamless. *The new checklist now includes an area to document expiration dates so that they can be replaced prior to their expiration. *The inspection of both First Aid Kits will be scheduled monthly, and those responsible for the inspection of both will be sent Outlook reminders. Person Responsible: Health & Wellness Dir. & Coord. Target Date of Completion: 10/9/23
22VAC40-73-70-A
Based on record reviewed and staff interviewed, the facility failed to ensure that it reported to the regional licensing office within 24 hours any major incident that has negatively affected the or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. On 9-30-23, staff #1 submitted to the licensing office, two incident reports for resident #9. The incidents noted falls and transporting to a local hospital due to resident acknowledging pain. These incidents occurred 9-21-23 and 9-23-23.
  2. On 10-2-23, the licensing office received an incident report for resident #10. The incident noted resident was hospitalized with a diagnosis of Acute Respiratory Failure with Hypoxia due to COPD and Exacerbation and UTI. This incident occurred on 9-23-23.
Plan of correction
*Resident #9 had 2 complete incident reports submitted on 9/30/23. *Resident #10 incident report was finalized and submitted on 10/2/23 *Effective 10/5/23, any “major incident” will now include any chronic or acute health conditions that result in a trip to the hospital emergency room. *All members of the Management Team, Registered Medication Aides, and those Designated in Charge will be educated on the requirement to report any event that has negatively affected or that threatens the life, health, safety or welfare of any resident to both the Executive Director and the Health & Wellness Director as soon as feasibly possible and no later than the end of their shift. *All Direct Care staff members to be re-educated on the importance of documenting those events in the resident’s electronic chart as soon as possible and no later than the end of their shift so that information needed for the DSS Incident Report is available to those responsible for submitting those reports. *This will be monitored/reviewed at the daily standup staff meetings. Person Responsible Exec. Dir., Health & Wellness Director, Family Advocate or Designee Target Completion Date 10/13/23 & Ongoing
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure that individualized service plan (ISP) included all assessed need.
Evidence
  1. On 9-25-23, resident #1’s ISP did not include the resident’s allergy to sulfa antibiotic, perfume, and animal dander. The ISP also did not include the resident’s assessed need for oxygen.
  2. Resident #2’s uniformed assessment instrument (UAI) dated 9-2-23 noted mobility assessed as no help needed. The ISP dated 7-14-23 noted resident needed mechanical help with mobility.
  3. Resident #5’s UAI dated 3-20-23 social data noted resident is an active organ donor. Resident’s physical examination document dated 1-20-23 noted resident is allergic to Percocet. These were not documented on the resident’s ISP dated 3-20-23.
Plan of correction
*Resident #1 ISP was updated to include the allergies to sulfa antibiotics, perfume, and animal dander. Her assessed need for O2 will also be added. *Resident #2 will be reassessed in the area of mobility to assure that her needs are accurate and match on the UAI and ISP. *Resident #5 ISP will be updated to reflect that she is an organ donor and also that she is allergic to Percocet. *The UAI/ISP audit tool will be used to gather detailed information needed for both documents to assure that all identified needs are captured and records, as required. *The UAI/ISP audit tool will also be used by the Exec. Dir., or appropriate Designee, when signing off to assure that all assessed needs are properly recorded on both the UAI & ISP. Responsible Person: Health & Wellness Dir. or Coord, Admin. Asst. & Exec. Dir. Target Date of Completion:10/25/23 & Ongoing
22VAC40-73-930-B
Based on observation and staff interviewed, the facility failed to ensure that the signaling device permitted staff to determine the origin of the signaling or is audible and visible in a manner that permits staff to determine the origin of the signal.
Evidence
  1. On 9-25-23 during a tour of the safe, secure unit with staff, the call bell in room #503 was pulled at 09:56 a.m. Staff members #4 and #6 were observed in the dining area of the unit. The inspector and staff #10 waited in the room and then came out of the room and waited for a staff to response to the call bell. Staff #10 stated the pager was observed on staff, however, neither staff #4 nor #6 responded to the call bell. At 10:06, the inspector inquired of staff if they heard the call bell. Staff #4 check the pager and stated not knowing the call bell had been alerted. Staff also stated that pagers do not always work, and the problem had been reported.
Plan of correction
*The Exec. Dir. duplicated the MBs doorbell and apt. #503 call bell on the evening of 9/25/23, and her pager operated properly. The other 3 pagers observed at the MBs Nurses Station and in the Med Room displayed the proper notifications for both the MBs doorbell and apt. #503. *All current Direct Care Staff will receive 1:1 training on how to operate, read, and reset the pagers used with the call bell system. This training will be documented. *All new hires will also receive 1:1 training on how to operate, read, and reset the pagers used with the call bell system. This training will also be documented. *This will be monitored by unannounced activation of various signaling devices to monitor Direct Care Staff response time. Person Responsible: Exec. Dir. & Maintenance Coord. Target Date of Completion: 10/25/23
22VAC40-73-1110-B
Based on record reviewed and staff interviewed, the facility failed to ensure that six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident’s continued residence in the special care unit.
Evidence
  1. On 9-25-23, resident #1’s record did not have documentation of continued appropriateness of place and continued residence. The resident’s dated of admit noted as 3-15-23.
Plan of correction
*Resident #1 had the Documentation of Continued Appropriate Placement completed. This will be uploaded into August Health. *All other MBs residents will have their files audited to assure that no other documents are past due. *Those responsible for completing this document will receive an Outlook reminder on the 1st of the month that the next document is due. Upon completion, they will be uploaded into August Health. Person Responsible: Health & Wellness Dir. & Coord., Exec. Dir. Target Date of Completion: 10/16/23
22VAC40-73-260-A
Based on record reviewed and staff interviewed, the facility failed to ensure that each direct care staff maintained current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.
Evidence
  1. On 9-25-23, staff #6’s record did not include current first aid within sixty days of hire. The staff’s date of hire was noted as 3-24-23 and first day of work noted as 4-5-23.
Plan of correction
*Bickford of Virginia Beach provides CPR & First Aid training to all staff members twice a year. Our most recent class was scheduled and conducted on 9/28/23. Staff #6 was on the list and did receive her recertification on 9/29/23. *A 100% audit of all personnel files was conducted to identify any Direct Care Staff who do not have current First Aid certification. *Proof of current First Aid certification is requested at the time of hire. For those who do not have current certification, it will be explained that they have 55 days from their start date to obtain the training and provide us with a copy of their card. On day 60, they will be removed from the schedule until the certification is received. Person Responsible: Exec. Dir., Admin. Asst. or Designee Target Completion Date: 10/18/23 & Ongoing
22VAC40-73-120-B
Based on record review and staff interview, the facility failed to ensure the orientation training included all required information.
Evidence
  1. On 9-25-23, the facility orientation document completed by staff #8 did not include purpose of the facility, daily routines, specific duties and responsibilities of the staff’s position and methods of alleviating common adjustments problems that may occur when a resident moves from one residential environment to another.
Plan of correction
*Staff member #8 to receive orientation training on the purpose of the facility, daily routines, specific duties and responsibilities of the staff member’s position, and methods of alleviating common adjustment problems that may occur when a resident moves from one residential environment to another. *All other active staff members will receive orientation training on the purpose of the facility, daily routines, specific duties and responsibilities of the staff member’s position, and methods of alleviating common adjustment problems that may occur when a resident moves from one residential environment to another. *Staff Orientation tools to be updated to reflect the inclusion of these topics. Person Responsible: Exec. Dir. or Designee
22VAC40-73-940-A
Based on document reviewed and staff interviewed, the facility failed to ensure it complied with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official.
Evidence
  1. On 9-25-23, the fire inspection provided to the inspector was dated 5-3-22.
  2. Staff #1 acknowledged the 5-3-22 fire inspection was the latest fire inspection for the facility.
Plan of correction
*The new Fire Marshall, Hope Scott, conducted the annual inspection on 10/12/23. She will forward the report on 10/13/23 and stated that things looked good. *It was explained that these inspections are required annually by DSS. *An Outlook reminder will be added for 11 months from today as a reminder to call the Fire Marshall’s office to schedule the annual inspection. Any difficulty with this process will be shared with the Exec. Dir. for follow up. Person Responsible: Maintenance Coord & Exec. Dir. Target Date of Completion: 10/12/23
22VAC40-73-450-F
Based on record reviewed and staff interviewed the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed for significant change of a resident’s condition.
Evidence
  1. On 9-25-23, resident #3’s uniform assessment instrument (UAI) dated 3-10-23 noted bathing and toileting assessed as independent. The ISP dated 3-10-23 noted resident needed mechanical help with bathing and toileting. Resident’s date of admit noted as 2-13-22.
  2. Resident #4’s ISP dated 8-15-23 did not include description of what services will be provided to address identified, who will provide them, when and where services will be provided and expected outcome time frame. The UAI dated 8-15-23 noted dressing need assessed as mechanical help/ physical assistance; the ISP did not identify the mechanical help. Toileting and transferring need assessed as mechanical help. The ISP did not identify the mechanical help. Eating/Feeding assessed as no help, the ISP noted resident requires “cueing to eat”. Bowel and bladder need assessed as less than weekly; the ISP did not address these needs. Walking need assessed as mechanical help; however, the resident does not walk. The resident is assessed as oriented; the ISP noted resident is forgetful, care support team to reorient, redirect and provide wayfinding.
  3. Resident #6’s UAI dated 7-22-23 noted toileting assessed as mechanical help/physical assistance. The ISP dated 7-24-23 did not identify the mechanical help needed. Transfer need assessed as mechanical help. The mechanical help need is not identified. Wheeling and stairclimbing need assessed as not performed; these needs were not addressed on the ISP. Resident’s physician order dated 7-7-23 noted the resident allergic to Amoxicillin, Guaifenesin, Sudafed PE, Loratadine and Shrimp. These items were not on the resident’s ISP, in addition the ISP did not include dated need was identified and expected outcome and time frame for expected outcome.
  4. Resident #7’s record included psychiatric services from a local agency, documented reports in record noted “psychiatric follow-up” dated 5-30-23, 7-4-23 and 7-18-23. The resident’s UAI dated 3-8-23 noted behavior pattern as abusive/aggressive/disruptive less than weekly, yelling and hitting. Resident’s orientation assessed as disoriented, some spheres all the time to place and time.
Plan of correction
*Resident #3 will be reassessed in the areas of bathing and toileting to assure that her needs are accurate and match on the UAI and ISP. *Resident #4 had the ISP updated to reflect what services will be provided to include: who will provide those services, when and where those services will be provided, the expected outcome and the time frame. This will be for the following identified needs: dressing to include the type of mechanical help, toileting and transferring to include the type of mechanical help, eating/feeding to include human help on the UAI, bowel and bladder incontinence less than weekly on the ISP, The status of walking with the walker to be assessed and updated on the UAI & ISP. The level of orientation to be corrected on the UAI and reflected on the ISP. *Resident #6 ISP to be updated with the type of mechanical help needed with toileting and what type of mechanical help is needed with transfers. Wheelchair and stairclimbing not addressed on the ISP. The ISP will be updated to include the date the need was identified, expected outcome and timeframe for expected outcome. *Resident #7 ISP to be updated to include psychiatric services, the behavior patterns, and level of orientation. *All ISPs in August Health to be reviewed and updated to assure that all identified needs have a date when the need was identified, the expected outcome, and the time frame for the expected outcome. It will also include who is performing the service, when the service is performed, how the service is performed, where the service is performed and why the service is performed. *They will be reviewed, using the Special Needs List & UAI/Service Plan Audit Tool and then signed. Target Date of Completion: 10/25/2023 & Ongoing
22VAC40-73-860-G
Based on observation and staff interviewed, the facility failed to ensure hot water at taps available to residents shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F.
Evidence
  1. On 9-25-23 during a tour of the facility, the water temperature in room #112 tested at 122 degrees Fahrenheit.
Plan of correction
*The temperature settings for the 100 hall were adjusted down by the Maintenance Coord., and apartment #112 now reads at 115 degrees. He used his thermometer, which was calibrated. *Apartment #112 was monitored daily, at alternating times, for 3 days, and the temperature is holding steady. *This will continue to be monitored on the temperature log Person Responsible: Maintenance Coord. or Designee Target Date of Completion: 9/29/23 & Ongoing
22VAC40-73-680-M
Based on observation, document reviewed, and staff interviewed, the facility failed to ensure medications ordered for PRN administration was available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. On 9-25-23 during the medication pass observation with staff #3, resident #4’s PRN Acetaminophen and Aero chamber noted on the physician’s order dated 7-7-23 were not available.
  2. Staff #3 acknowledged the resident’s PRN were not available on 9-25-23.
Plan of correction
*Resident #4 PRN Acetaminophen and Aero Chamber were re-ordered and arrived on 9/26/23 *A 100% audit to be conducted on all MARs with PRN medications to assure that they are on hand. *The 4 Hour Med Tech Refresher course training was provided to our RMAs on 10/10/23, which included the procedure for re-ordering routine & PRN medications. *This will be monitored weekly during the Medication Audits. Person Responsible: Health & Wellness Dir., Coord, or Designee Target Date of Completion: 10/10/23 & Ongoing
22VAC40-73-220-A
Based on record review and staff interviewed, the facility failed to ensure when private duty personnel from licensed home care organizations provide direct care or companion services to residents in an assisted living facility, the facility shall provide orientation and training to the private duty personnel.
Evidence
  1. On 9-25-23, a private duty personnel was observed accompanying resident #5 to the medication room. CS-1 record did not include documentation on the type and frequency of services to be delivered to the resident by the private duty personnel. The facility failed to ensure that the requirements regarding tuberculosis (TB) were met; CS-1’s TB was dated 4-1-22. The facility did not have documentation of orientation and training to CS-1 regarding the facilities policies and procedures related to the private duty personnel’s duties.
  2. Staff #1 acknowledged the required training, orientation and documentation for CS-1, private duty personnel for resident #5 was not completed.
Plan of correction
*CS-1 private duty file was updated to reflect documentation on the type and frequency of services to be delivered to the resident by the private duty personnel, obtained a current TB Screening, and provided orientation and training to CS-1 regarding the facilities policies and procedures related to the private duty personnel’s duties. *Audit any other CS private duty files to assure that they are current and updated, as needed. *Contacted the company who provides resident #5 private duty personnel and again provided them with a copy of DSS Standard 22VAC40-73-220-A regarding their responsibilities and our requirements regarding any private duty personnel working in our Branch. It was stressed that these requirements must be met prior to them beginning services. Also requested that they track and then initiate any changes to their schedule or services provided so that the residents Service Plan can be updated and track when the annual TB screening is due. We will also set up an Outlook reminder of that due date. *CS Private Duty files will be audited and updated at the time of that Outlook reminder. Person Responsible: Exec. Dir., Admin. Asst. or Designee Target Completion Date: 10/18/23 & Ongoing
22VAC40-73-470-A
Based on record reviewed and staff interviewed, the facility failed to ensure either directly or indirectly, that the health care service needs of residents are met.
Evidence
  1. On 9-25-23, resident #7’s record included a physician’s order dated 4-25-23 for occupational therapy, “OT please eval and tx; cervical spinal stenosis, arthrosclerosis of c spine, paresthesia upper extremity, DJD c-spine” The record did not include documentation of therapy services. The individualized service plan did not include services beginning or ending.
Plan of correction
*Resident #7 record to be uploaded with the OT documentation ordered 4/25/23, and the ISP will be updated to include the beginning/ending dates. *Fox Rehab caseload list to be reviewed to assure that all current resident eCharts, August Health, have therapy notes scanned and uploaded. *The updated Special Needs list will be used weekly to monitor that the Fox Rehab notes have been uploaded into August Health. Person Responsible: Exec. Dir. & Admin. Asst. Target Date of Completion: 10/25/2023 & Ongoing
22VAC40-73-450-D
Based on record reviewed and staff interviewed, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate an established an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP).
Evidence
  1. On 9-25-23, resident #1’s ISP did not include hospice services being provided; neither the various services being provided to the resident.
  2. Resident #6’s ISP did not include the resident received hospice services; neither the various services being provided to the resident (social worker, chaplain, aide, and skilled nursing).
Plan of correction
*Resident #1 ISP to be updated to include Hospice designation and services being provided. The Hospice provider’s Plan of Care will be utilized for this process. *Resident #6 ISP to be updated to include Hospice designation and services being provided. The Hospice provider’s Plan of Care will be utilized for this process. *The Special Needs List will be used to audit any other residents receiving Hospice services to assure that the required information is included on those ISPs. *The Special Needs List will be updated weekly by the Health & Wellness Dir. and/or Coord. and given to the Admin. Asst. each Monday to update and will be used to review ISPs to assure that the recent changes to the Special Needs list have been updated on the ISPs Person Responsible: Health & Wellness Dir. or Coord, Admin. Asst. & Exec. Dir. Target Date of Completion: 10/25/2023 & Ongoing
22VAC40-73-310-H
Based on records reviewed and staff interviewed, the facility failed to ensure it did not admit retain individuals with a prohibitive conditions or care needs.
Evidence
  1. On 9-25-23, resident #5’s record included an order dated 7-12-23 for Sertraline and Trazodone (start date 1-27-23). The record did not include a psychotropic treatment plan for these medications.
  2. Resident #6’s physician order dated 7-7-23 for Haloperidol and Lorazepam (start date 6-9-23). Trazadone noted with a prescribed with a start date of 7-27-23. The record did not include a psychotropic treatment plan for these medications.
Plan of correction
*Resident #5 had the Psychotropic Treatment Plans completed for Sertraline and Trazadone and both were uploaded to their eChart, August Health *Resident #6 had the Psychotropic Treatment Plans completed for Haloperidol, Lorazepam and Trazadone and all 3 were uploaded to their eChart, August Health *All resident Physician Order Sheets to be audited to assure that there is a Psychotropic Order Sheet for each medication in this category. Any noted to be missing are to be obtained from the Provider and uploaded to the residents eChart, August Health. *The Providers seeing patients at the Branch had blank Psychotropic Treatment Plan forms (with instructions) added to their Provider binders. *Health & Wellness Dir., Coord., and RMAs instructed to request this form each time an order for a Psychotropic is received and not to submit it to be filled without this portion of the order. *Compliance to be monitored during weekly medication audits. Person Responsible: Health & Wellness Dir., Coord. or Designee Target Date of Completion: 10/25/23 & Ongoing
22VAC40-73-100-C-2
Based on observation and staff interviewed, the facility failed to ensure the facility’s infection control policy was implemented during the medication pass observation.
Evidence
  1. On 9-25-23 during the medication pass observation with staff #3, resident #5’s blood sugar was checked. The staff was observed removing the glucometer from the container and placing it on top of the medication cart. Next the staff placed the glucometer on counter behind the medication cart next to the oscillating fan that was in use. The glucometer was not sanitized prior to the finger stick be conducted.
Plan of correction
*An in-service for the Registered Medication Aides was conducted by the Divisional Nurse on 10/10/23 and included Administration of Insulin, Medication Administration, and Designated Person In Charge Duties And Responsibilities. Documentation of such will be maintained in their personnel file/training record. *All newly hired RMAs, as a part of their initial orientation, will review Bickford’s policies on Administration of Insulin, Medication Administration, and Designated Person In Charge Duties And Responsibilities. Documentation of such will be maintained in their personnel file/training record. * All RMAs will review these policies annually during the 4 Hour Med Tech Refresher course, and documentation of such will be maintained in their personnel file/training record. *This requirement will be added to the personnel file audit tool, and compliance will be monitored during personnel file audits. . Person Responsible: Health & Wellness Dir., Coord., Divisional Nurse or Designee Target Completion Date: 10/10/23 Ongoin
22VAC40-73-1180-B
Based on observation and staff interviewed, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision.
Evidence
  1. On 9-25-23 during a tour of the safe, secure unit with staff #10, a heavy steel iron was observed on unit in the “Sewing is my therapy” activity section.
  2. Staff #4 acknowledged the item was not appropriate for the residents on the unit.
Plan of correction
*This vintage iron was a part of one of our Life Stations and was removed at that time. *Because this can be very subjective, all items purchased or received as donations will be looked at closely by our management team for a collective decision on whether those items intended for the stimulation and enjoyment of our Mary Bs residents poses any obvious safety hazards. Person Responsible: Exec. Dir., Family Advocate, Health & Wellness Dir. and Coord. Target Date of Completion: 9/25/23
July 17, 2023Complaint survey2 violations
Inspection dates
07/17/2023,07/24/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint An on-site complaint inspection conducted on 7-17-23 (Ar 10:45 a.m./ dep p.m.) 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 6-26-23 regarding allegations in the resident care and related services (medication). Number of residents present at the facility at the beginning of the inspection: 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: Number of interviews conducted with residents: Number of interviews conducted with staff: Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law A violation notice was 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 (Willie Barnes), Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on record reviewed and staff interviewed, the facility failed to ensure that medications shall be administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. On 7-17-23, during a complaint inspection regarding medication not being administered, resident #1’s June 2023 medication administration record noted resident’s #1’s antibiotic was not administered. The resident was prescribed an antibiotic for 10 days, and to be administered twice a day. The June 2023 MAR for the 6-24-23 scheduled dosage at 8 p.m. was noted as not given.
  2. Staff #3 stated attempt was made to assist staff #4 in locating resident #1’s medication but was rebuffed by staff #4 and the resident did not receive the medication, because staff #4 was not able to locate the medication on the cart.
Plan of correction
The Agency who provided the Registered Medication Aide for the 3-11 shift on 6/24/23 was notified on 6/25/23 by our Health & Wellness Dir., via their public 5-star rating system, that she was not a good fit and gave her a 1 star. *Resident #1 Provider was notified on 6/26/23 of the single dose not given by the Agency staff member and the 4 doses refused by the resident to receive additional instructions. *Moving forward, our goal is to have a staff member/RMA administer medications verses Agency personnel. If this is unavoidable, it will be the responsibility of the Health & Wellness Dir. or Coord. to review the medication variance report at the end of that shift to assure that the Agency personnel administered all medications and documented appropriately. Person Responsible: Health & Wellness Dir. or Coord. Target Completion Date: 7/28/23 & Ongoing
22VAC40-73-70-A
Based on staff interviewed and documented reviewed, the facility failed to report the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health or safety of any resident.
Evidence
  1. On 7-17-23 during a complaint inspection regarding residents not receiving medication, staff #1 acknowledged there was a medication error for resident #1 on 6-24-23. The licensing department received the incident on Tuesday, June 27, 2023 at 12:17 a.m.
Plan of correction
The incident involving the single dose of medication not given by the Agency personnel to Resident #1 on 6/24/23 should have been formally reported to DSS no later than 6/25/23. *The Health & Wellness Dir. was educated on the necessity to report to the Exec. Dir. any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident so that guidance can be given and timely reporting can take place. *In the absence of the Exec. Dir., the Health & Wellness Dir., the Health & Wellness Coord., and the Family Advocate (in that order) are authorized to make the initial notification of a reportable event to DSS/Licensing Specialist within 24 hours of the event/notification of the event with the Final Notification being submitted within 7 days. Each will be educated on this process. *When notification of a reportable event has been made to DSS, an Outlook reminder will be sent to those mentioned above on day 5 as a reminder that the final report is due no later than day 7. Responsible Person: Exec. Dir., Health & Wellness Dir., Health & Wellness Coord., and Family Advocate Target Completion Date: 7/28/23 & Ongoing
June 20, 2023Complaint survey2 violations
Inspection dates
06/20/2023,07/17/2023
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: Complaint An on-site complaint inspection conducted on 6-20-23 (Ar 09:40 a.m./ dep 2:50 p.m.) Th The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. An on-line complaint was received by VDSS Division of Licensing on 5-16-23 regarding allegations in the resident care and related services (medication) and staff training/knowledge. 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: 2 Number of staff records reviewed: Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: resident with oxygen/O2 posting on bedroom door Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law A violation notice was 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 (Willie Barnes), Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on observation, record reviewed and staff interviewed, the facility failed to ensure the resident’s individualized service plan (ISP) was updated to address significant change of a resident.
Evidence
  1. On 6-20-23, resident #1’s uniformed assessment instrument (UAI) noted transferring assessed as mechanical help (mh). The ISP dated 3-10-23 did not identify what mechanical device was needed for assistance. Stairclimbing assessed as mh. The ISP documented physical assistance from staff and mh, however, the mechanical device is not identified. The resident was observed using oxygen in the bedroom. The record included an order for 2L Nasal cannula- continuous oxygen. This was not on the ISP. The resident also receives psychiatric services from a local agency, this need was not addressed on the ISP. The resident’s date of admit noted as 1-17-22.
Plan of correction
Not published by VDSS.
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s comprehensive individualized service plan (ISP) included all assessed needs.
Evidence
  1. On 6-20-23, resident #2’s uniformed assessment instrument (UAI) dated 3-20-23 documented walking as mechanical help/supervision (mh/s. This assessed need was not documented on the ISP dated 3-30-23. Wheeling and walking need assessed as mechanical help/supervision. The ISP did not document walking need and wheeling noted companion pushing resident in wheelchair to areas in facility. The record included physical therapy services dated 3-31-23 and occupational therapy services dated 4-13-23. These therapy services were not documented on the ISP. The ISP did not include resident psychiatric services from a local agency. The record noted the resident has a companion; this service is not noted on the ISP. The resident’s date of admit noted as 1-27-23 (initially respite, then returned admission).
Plan of correction
The licensee/provider did not provide a plan of correction by the due date.
June 20, 2023Complaint survey2 violations
Inspection dates
06/20/2023,07/17/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint On-site complaint inspection conducted on 6-20-23 (Ar 09:40 a.m./ dep 2:50 p.m.) 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 5-18-23 regarding allegations in the area of resident care and related services (medications) 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: Number of staff records reviewed: Number of interviews conducted with residents: Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation 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 (Willie Barnes), Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on staff interviewed and documented reviewed, the facility failed to ensure medication was administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. On 6-20-23 during a complaint inspection regarding residents in the facility not receiving medications, staff #1 provided the inspector with a list with the names of residents who did not receive medications on April 30, 2023, May 1, 2023 and May 2, 2023.
  2. A list of the medications for residents’ who did not receive medications as prescribed was also provided.
  3. There were forty-one (41) residents who did not receive medications a variety of medications as prescribed because the medications were not available in the facility to be administered. According to staff #2, the facility pharmacy had to be contacted to request it send medications to cover the days medications would not be available until the next re-supply date was scheduled. The medications for the April 30th day thru May 2 were with the April-May scheduled days bubble packets (April 5 to May 4th) but was not able to be located to the residents on April 30, 2023.
  4. Staff #1 and #2 acknowledged residents’ medications were not available in the facility to administer. The facility contacted its pharmacy manager to have additional medications sent to the facility to cover the missing medications.
Plan of correction
*The missed doses of medications referenced in Violation Notices dated 5/15/23 and 5/20/23 were delivered by the pharmacy on 5/2/23, along with May 2023 Cycle Fill medications, and were billed to and paid for by the Bickford of Virginia Beach. *Any resident or residents found to be out of any medications are to be called into the pharmacy during routine business hours or called into the “after hours” pharmacist on call immediately so that a refill can be called into the local backup pharmacy to be filled timely. Director on Call will be responsible for picking up the prescriptions from the local pharmacy and delivering them to the Branch. *If there are any missed doses by residents, the prescriber will be notified by the Health & Wellness Dir.or Coord. This will be documented. *The Exec. Dir. is also to be notified immediately of any resident/residents who are without medications so that assistance/guidance can be provided, as needed. This includes managing any additional notifications that may be required. Person Responsible:Exec. Dir., Health & Wellness Dir., Health & Wellness Coord., and Family Advocate Target Completion Date: 7/28/2023
22VAC40-73-70-A
Based on staff interviewed and documented reviewed, the facility failed to report the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health or safety of any resident.
Evidence
  1. On 6-20-23 during a complaint inspection regarding residents not receiving medications, staff #1 presented the inspector with a list of residents whose medications needed to be re-ordered prior to the facility’s scheduled re-stocking date.
  2. Staff #1 acknowledged not reporting the medication error per the facility Incident and Accident Report (PP-31000).
Plan of correction
*The incident involving the medications that needed to be reordered prior to the re-stocking date occurred on 4/30/23 - 5/2/23. This incident should have been formally reported to DSS no later than 5/3/23. *Staff #1 presented the final documents and billing statement on 6/20/23 in conclusion of the above referenced incident. *The Health & Wellness Dir. was educated on the necessity to report to the Exec. Dir. any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident so that guidance can be given and timely reporting can take place. *In the absence of the Exec. Dir., the Health & Wellness Dir., the Health & Wellness Coord., and the Family Advocate (in that order) are authorized to make the initial notification of a reportable event to DSS/Licensing Specialist within 24 hours of the event with the Final Notification being sent within 7 days of the event. Each will be educated on this process. *When notification of a reportable event has been made to DSS, an Outlook reminder will be sent to those mentioned above on day 5 as a reminder that the final report is due no later than day 7. Person Responsible: Exec. Dir., Health & Wellness Dir., Health & Wellness Coord., and Family Advocate Target Completion Date: 07/28/2023 and Ongoing
May 15, 2023Complaint survey6 violations
Inspection dates
05/15/2023,05/16/2023, 06/20/2023, 07/17/2023
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: Complaint A joint complaint inspection with APS was conducted on 5-15-23. The Inspector visited facility also on 5-16-23. 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 5-9-23 regarding allegations in the resident care and related services (medication). Number of residents present at the facility at the beginning of the inspection: 59 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: Number of interviews conducted with residents: Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email willie.barnes@dss.virginia.gov
Violations
22VAC40-73-440-D
Based on record reviewed and staff interviewed, the facility failed to ensure uniform assessment instrument for private pay individual was completed as required.
Evidence
  1. On 5-15-23, resident #1’s UAI dated 5-4-23 was not signed and dated by another facility staff, when the assessor who completed the form was identified as a facility staff member.
  2. On 5-16-23, resident #2’s UAI dated 1-10-23 was not signed by another facility staff member when the assessor who completed the form was identified as a facility staff member.
Plan of correction
Not published by VDSS.
22VAC40-73-320-B
Based on record reviewed and staff interviewed, the facility failed to ensure an annual risk assessment for tuberculosis (TB) was completed for a resident as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. On 5-16-23, during a complaint inspection, resident #3’s TB screening in the record was dated 10-24-21.
  3. Staff #2 was not able to locate a recent screening for the aforementioned resident.
Plan of correction
Not published by VDSS.
22VAC40-73-680-D
Based on record reviewed and staff interviewed, the facility failed to ensure medications was administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. On 5-15-23 during a joint complaint inspection allegation of resident #1 being admitted to the hospital due to not receiving medications, the interview with staff #1 and #2 confirmed resident did not receive medications. Documentation in the resident’s record noted resident was admitted to a local hospital on 5-2-23 and discharged on 5-5-23. The resident’s record noted resident did not receive the following medications on 4-30-23: (a) Arthritis pain, (b) Coreg, (c) Entresto, (d) Keppra and (e) Trileptal. The following were noted as not administered on 5-1-23 (a) Arthritis pain, (b) Coreg, (c) Digoxin, (d) Eliquis, (e) Entresto, (f) Lasix, (g) Keppra, (h) Loperamide, (i) Multivitamin, (j) Trileptal, (k) Zoloft, (l) Aldactone and (m) Vitamin D. Interview with staff stated the medications were not available to administer. Further interview revealed the medications were not available because it may have been thrown away. According to staff #2 the facility medications for the cycle is received on the 3rd or 4th of the month; residents medication for the 30th day of the current month and 1st, 2nd and 3rd day of the next month is included in the current month blister pack.
  2. During the joint interview, it was stated by staff #1 and #2 that there were several residents who did not receive medication. The staff did not give a specific number. Residents #2, #4, #5 and #6’s medication administration record (MAR) for April 2023 and May 2023 were reviewed for medication not being administered. Resident #4 and #5’s record noted medication not being administered, awaiting pharmacy delivery.
  3. Staff #1 and #2 acknowledged there were residents’ who did not receive their medications because it was not in the facility to administer. According to staff #1, the medication was reordered from the facility’s out of -state pharmacy as “replacement medications”.
Plan of correction
The provider/licensee did not provide a plan of correction by the due date.
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure comprehensive individualized service plan (ISP) included all assessed needs.
Evidence
  1. On 5-16-23, resident #2’s uniform assessment instrument (UAI) dated 1-10-23 documented wheeling and stairclimbing need assessed as mechanical help (mh). The ISP dated 1-10-23 did not include these assessed needs. The resident’s record included documentation of psychiatric services, 2-7-23 and 3-7-23 for psychotropic medications. This service was not documented on the ISP.
Plan of correction
Not published by VDSS.
22VAC40-73-450-E
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator or his designee, and by the resident or his legal representative.
Evidence
  1. On 5-15-23 during a joint complaint inspection, resident #1’s ISP dated 5-4-23 was not signed by the resident and/or the resident’s representative.
Plan of correction
Not published by VDSS.
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all updated and/or significant changes.
Evidence
  1. On 5-15-23, resident #1’s uniform assessment instrument (UAI) dated 5-4-23 documented toileting as mechanical help/human help/physical assistance. The ISP documented resident toilets with reminders, use of handrails to transfer. Stairclimbing assessed as mechanical help/ human help/physical assistance. The ISP documented use of handrails. The record included a physician’s order dated 2-13-23 for resident’s food to be cut up due to dysphagia. This assessed need was not on the UAI and not on the ISP.
  2. Resident #3’s UAI dated 11-21-22 documented bathing assessed as mechanical help. The ISP dated 5-21-22 documented physical assistance by staff to wash lower extremities. Mobility assessed as mechanical help. The ISP did not include this assessed need.
  3. On 5-16-23, resident #4’s UAI dated 3-10-23 documented transferring need as mechanical help. Stairclimbing assessed as mechanical help. The ISP documented mechanical help/ physical assistance; however, the mechanical device was not identified. The ISP dated 3-10-23 did not include this assessed need. The was observed using Oxygen. A check of the resident physician’s order documented resident’s use of oxygen (2 LPM via NC continuous). Resident also receives psychiatric services which was not on the ISP.
Plan of correction
Not published by VDSS.
May 1, 2023Inspection4 violations
Inspection dates
05/01/2023, 05/15/2023,07/17/2023
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring An on-site monitoring inspection following IPOC was conducted on 5-1-23 (Ar 09:38 a / Dep 4:05 p). The facility census was 61. The administrator was not present but arrived later. Resident’s records were reviewed and a medication pass was conducted. The inspections repeat violations facility IPOC plan reviewed with administrator and staff. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition for one of three records reviewed.
Evidence
  1. Resident #3’s UAI dated 1-8-23 documented dressing as mechanical help/human help/physical assistance. The ISP dated 1-8-23 did not document what mechanical help was needed. Bladder was not documented as an assessed need on the UAI. The ISP documented family provides incontinent products. The skilled nursing and occupational therapy services documents also noted resident was incontinent of bladder. Stairclimbing, walking and mobility assessed as mechanical help (mh). The ISP did not document stairclimbing need; mobility documented resident able to walk short distances, resident required mechanical help and physical assistance. Mobility documented resident walk short distances/ physical and mechanical help needed. Resident’s record included physician’s orders dated 1-5-23 for Physical therapy, Occupational Therapy and Speech Therapy, this was not documented on the ISP. The record included therapy service notes certified 2-23 to 4-23-23. The record also included occupational therapy discharge service date 3-9-23. The ISP did not include this change. A physician’s order dated 2-17-23 for PT/OT and Una boot for bilateral lower extremity (BLE) was in the record. These services were not documented on the resident’s ISP. The resident’s date of admit was noted as 6-11-20.
Plan of correction
* Resident #3 will have the UAI assessment and Service Plan (ISP) updated to include what current type of mechanical help is needed with dressing, what current type of bladder care is needed (to include the provision of supplies), what the current stairclimbing/walking/ mobility mechanical/physical assistance needs are, and the current PT/OT/SP start dates/needed services/adaptive equipment (Una Boot)/frequency if indicated. *Bickford of Virginia Beach is transitioning to August Health, an electronic documentation system which will capture needs identified on the electronic UAI assessment and accurately transfer them to the Service Plan (ISP). From there, each identified need will be individualized. At this time, all residents are having new UAI assessments and Service Plans completed in August Health as a part of the implementation of this new system. *All Assessments and Service Plans will be reviewed\approved by the Exec. Dir./Designee as required and can also be monitored virtually by Divisional Leadership. Person Responsible: Health & Wellness Director & Coordinator/ Designee and the Exec. Dir Target Completion Date: 8/10/23 and Ongoing
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for two of three resident’s record.
Evidence
  1. On 5-1-23, resident #1’s uniform assessment instrument (UAI) dated 3-16-23 documented dressing (AM/PM care) need as mechanical help/human help/supervision (mh/hh/s). The individualized service plan (ISP) dated 3-17-23 documented resident required staff cueing and physical assistance/ standby assist to complete task. There was no documentation of what mechanical help was needed. Bathing need assessed as mh/s. The ISP documented staff to wash missing areas and hard to reach areas and step by step cueing. Toileting assessed as mechanical help (mh). The ISP documented resident is independent. Walking, stairclimbing, wheeling and mobility assessed as mechanical help (mh). The ISP documented mobility/escorts, resident self-propel wheelchair. The ISP did not include walking and stairclimbing. Physical therapy, occupational therapy and speech therapy documented on ISP; however, services start date, what services and when services were provided was not documented on the ISP. Resident’s date of admit noted as 3-17-23.
  2. Resident #2’s UAI dated 3-30-23 not bathing needs assessed as mechanical help/human help/supervision (mh/hh/s). The individualized service plan dated 4-4-23 documented resident needed physical assistance for bathing.
Plan of correction
*Residents #1 will have the Service Plan (ISP) updated to include what current type of mechanical help is needed with dressing and toileting, what physical help is needed with bathing at this time, how stair climbing and walking are currently performed, and PT/OT/SP start dates/needed services/frequency if indicated. *Resident #2 will have the Service Plan (ISP) updated for bathing to include what type of mechanical help is currently needed and whether supervision or physical help is needed at this time. *Bickford of Virginia Beach is transitioning to August Health, an electronic documentation system which will capture needs identified on the electronic UAI assessment and accurately transfer them to the Service Plan (ISP). From there, each identified need will be individualized. At this time, all residents are having new UAI assessments and Service Plans completed in August Health as a part of the implementation of this new system. *All Assessments and Service Plans will be reviewed\approved by the Exec. Dir./Designee as required and can also be monitored virtually by Divisional Leadership. Person Responsible: Health & Wellness Director & Coordinator/ Designee and the Exec. Dir, Target Completion Date: 8/10/23 and ongoing
22VAC40-73-680-C
Based on observation, record reviewed and staff interviewed, the facility failed to ensure medications shall 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. On 5-1-23, during the medication pass observation with staff #3, the inspector inquired and was informed that there were three other residents who needed to receive medications. The time on the facility’s medication screen was 10:53 a.m.
  2. Resident #4 did not receive the prescribed mediation according to the scheduled dosing time. The following medications were scheduled for 9:00 a.m.: (a) Arthritis pain, (b) Artificial Tears, (c) Coreg, (d) Digoxin, (e) Eliquis, (f) Entresto, (g) Lasix, (h) Keppra, (i) Imodium, (j) Multivitamin, (k) Trileptal, (l) Restasis, (m) Zoloft, (n) Aldactone and (o) Vitamin D.
  3. Resident #5 did not receive the prescribed medication according to the scheduled dosing time. The following medications were scheduled for 8:00 a.m.: (a) Vitamin B-12 injection, and (b) Pepcid. The following medications were scheduled for 9:00 a.m.: (a) Synthroid, (b) Multivitamin, (c) Sanctura XR, (d) Valsartan and (e) Vitamin D3. Ensure was scheduled at 10:00 a.m.
  4. Resident #6 did not receive the prescribed medication according to the scheduled dosing time. The following medications were scheduled for 9:00 a.m.: (a) Albuterol nebulizer, (b) Uroxatral, (c) Lipitor, (d) Aero inhaler, (e) Alphagan, (f) Eliquis, (g) Fenofibrate, (h) Hydrazaline, (i) Irbesartan, (j) Singular, (k) Procardia, (l) Vitamin B-12 and (m) Vitamin D2.
Plan of correction
*The Providers for Residents #3, #4, #5, & #6 were notified that their patients received their medications late on 5/1/23. There were no new orders. *Bickford of Virginia Beach has received a second med cart to be used for Assisted Living, due to the quantity of medications ordered. Assignments and med pass times will be evaluated and adjusted to allow for the additional time/manpower needed to pass all prescribed medications within the allowed timeframe. *This will be monitored weekly by the Health & Wellness Dir. & Coord. during the Weekly Medication Variance Audits. Person Responsible: Health & Wellness Dir. and Coord. Target Date of Completion: 8/4/23 and Ongoing
22VAC40-73-640-A
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition for one of three records reviewed.
Evidence
  1. Resident #3’s UAI dated 1-8-23 documented dressing as mechanical help/human help/physical assistance. The ISP dated 1-8-23 did not document what mechanical help was needed. Bladder was not documented as an assessed need on the UAI. The ISP documented family provides incontinent products. The skilled nursing and occupational therapy services documents also noted resident was incontinent of bladder. Stairclimbing, walking and mobility assessed as mechanical help (mh). The ISP did not document stairclimbing need; mobility documented resident able to walk short distances, resident required mechanical help and physical assistance. Mobility documented resident walk short distances/ physical and mechanical help needed. Resident’s record included physician’s orders dated 1-5-23 for Physical therapy, Occupational Therapy and Speech Therapy, this was not documented on the ISP. The record included therapy service notes certified 2-23 to 4-23-23. The record also included occupational therapy discharge service date 3-9-23. The ISP did not include this change. A physician’s order dated 2-17-23 for PT/OT and Una boot for bilateral lower extremity (BLE) was in the record. These services were not documented on the resident’s ISP. The resident’s date of admit was noted as 6-11-20.
Plan of correction
*The Health & Wellness Dir. reviewed all of the medications for Resident #1 and assured that all were on hand. *The Health & Wellness Dir. and Coord. reviewed all other resident medications provided by their families to assure that all were on hand. *Those Families/Responsible Parties will be emailed regarding their responsibility with regards to assuring that our resident has all ordered medications on hand to give at all times. *If a Family/Responsible Party fails to provide a medication/refill on time, the resident’s Provider will be asked to call in a refill to our local backup pharmacy, and a conversation will be had with that Family/Responsible Party regarding their responsibility and the potential of switching to our commercial pharmacy for reliability purposes. *This will be monitored weekly by the Health & Wellness Dir. and Coord. during the weekly Medication Variance Audits Person Responsible: Health & Wellness Dir. and Coord./Designee Target Date of Completion: 8/1/23
November 30, 2022Inspection9 violations
Inspection dates
11/30/2022,12/13/2022,12/5/2022,12/19/2022,12/27/2022,12/29/2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal An unannounced renewal inspection was conducted on 11-30-22 (ar 07:35 a.m./dep 20:00 p.m.) The census on day one was 60. A tour of the facility was conducted, medication pass observed, staff and resident interviews and records reviewed, emergency preparedness reviewed, `breakfast meal observed. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-680-M
Based on observation and staff interviewed, the facility failed to ensure medications ordered for PRN administration was available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. On 11-30-22 during medication pass observation with staff #5, resident #3’s PRN Tylenol was not available in the facility.
  2. Resident #5’s PRN Lotrisone, Loperamide and Vaseline not available in the facility.
  3. Resident #6’s PRN Senna Plus and Citrucel not available in the facility.
Plan of correction
*Residents #3, #5, & #6 had their identified PRN medications re-ordered to assure that they are on site and available to give if needed. *All residents with PRN medication orders will be audited by the Health and Wellness Director to assure that all prescribed PRN medications are on site and available to give, if needed. *All Medication Aides will be re-educated on the need to request refills from the pharmacy for any resident who needs their PRN medications refilled and will immediately report to the HWC any challenges with that process. *This will be monitored during weekly Medication Audits. Person Responsible: HWD or Designee Target Date of Completion: 1/13/2023 and Ongoing
22VAC40-73-40-A
Based on documents reviewed and staff interviewed, the facility failed to ensure it complied with its policy regarding criminal record check.
Evidence
  1. On 11-30-22, the facility staff listing of new employees noted staff #7’s date of hire as 8-21-22. Staff #7’s criminal record check (CRC) received on 12-5-22 was dated 8-31-22.
  2. On 12-27-22, following the facility’s third preliminary exit, staff #1 provided the inspector with staff #7’s timesheet noting first day of work as 8-30-22 and date of hire as 8-21-22.
  3. The facility’s policy document staff’s criminal record check to be received prior to beginning work.
Plan of correction
*Staff #7 start date was 8/30/22. The negative criminal history report was received on 8/31/22, and her sworn disclosure with no pending or conviction data was received on 8/24/22. Although regulations allow 30 days to receive the results, Bickford’s policy is to obtain the results prior to starting. *Moving forward, staff will not be permitted to start orientation “on-site” until the background check is complete. *All active staff records will be audited, and properly notated, to identify any other records containing a background check received after the “on-site” start date. *Any new hires with a “pending” background check result from the VA State Police will be told that they cannot start until the report is received in the mail and approved. Person Responsible: Exec. Dir. or Designee Target Completion Date: 12/27/22 & Ongoing
22VAC40-73-640-A
Based on observation and staff interviewed, the facility failed to ensure it implemented it medication management plan for proper disposal of medication.
Evidence
  1. On 11-30-22 during the medication observation pass with staff #5, the staff went to a container with multiple medications to check for a PRN medication for resident #5.
  2. When inquired why the observed medications were being collected in this box. Staff stated the container contained medications that were discontinued.
  3. A count of the medication packages and containers determined that there were fifty packets/containers of medications for sixteen residents. The medication dates range from March 2022 to October 2022 and included medications of various categories, over-the counter medications, psychotropic medications, controlled substances, hospice medications.
  4. The facility medication management policy PP-61050 for VA, disposal instructions on page 6 was not conducted by facility staff. Controlled medications which need to be dispose were not kept under double lock, medications that could be returned to pharmacy were not returned. The facility policy regarding destruction of medications were not conducted in a timely manner as plan stated.
Plan of correction
*The Health and Wellness Director immediately removed all identified medications from the secured medication room and properly disposed of them, per Bickford policy, on 12/1/22 *Moving forward, all discontinued medications or those prescribed for residents who have been discharged, will be properly disposed of within 7-14 days. *This process will be monitored during weekly Medication Cart Audits conducted by the HWC. Person Responsible: HWD or Designee Target Date: 12/27/2022 & Ongoing
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for four of six residents.
Evidence
  1. On 11-30-22, resident #1’s uniformed assessment instrument (UAI) dated 5-2-22 and 7-11-22 documented stairclimbing needs assessed as mechanical help/physical assistance. The resident’s ISP dated 7-11-22 did not include this assessed need.
  2. Resident #2’s UAI dated 7-5-22 and 8-10-22 documented transferring as mechanical help, wheeling and stairclimbing as not performed. The ISP dated 7-8-22 did not include these assessed needs.
  3. Resident #4’s UAI dated 3-23-21 and 6-15-22 documented wheeling as not performed and stairclimbing as mechanical help/physical assistance. These assessed needs were not on the ISP dated 6-15-22 (received from staff #2 on 12-13-22).
  4. Resident #6’s UAI dated 9-21-21 and 3-16-22 documented dressing, toileting and transferring as mechanical help/physical assistance. The ISP dated 6-8-22 did not include the mechanical assistance for dressing, toileting and transferring. Stairclimbing documented as not performed, this assessed need was not documented on the ISP. The record included documentation of speech therapy services (10-5-22, 10-25-22 and 8-27-22). This service was not documented on the ISP.
Plan of correction
*Residents #1 current Service Plan will be updated to reflect the current stair climbing needs. Resident #2 current Service Plan will be updated to reflect the current transferring, stair climbing, and wheeling needs. Resident #4 current Service Plan will be updated to reflect the current stair climbing needs, & Resident #6 current Service Plan will be updated to reflect the current dressing, toileting, transferring, and stair climbing needs. *All resident Service Plans are in the process of being reviewed and updated, per our policy, and the needs identified on the UAI will be audited against the Service Plan by the BFM who completed it to assure that all needs are accurately reflected on the Service Plan. *The UAIs and Service Plans will be audited a second time by the Dir., or designee, at the time of signature, to assure that all identified needs on the UAI are reflected on the Service Plan. Person Responsible: HWC/Exec.Dir/ or Designee Target Date: 1/25/23 & Ongoing
22VAC40-73-380-B
Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s personal and social information placed in resident’s record was kept current.
Evidence
  1. On 11-30-22, resident #1’s social data was not updated to include resident’s allergies. The allergy section was blank. The resident’s uniform assessment instrument (UAI) dated 5-2-22 and 7-11-22 noted in the comment section resident’s allergy to Sulfa antibiotic and statin drug allergies.
Plan of correction
* Resident #1 had the allergies updated on the Social Data Form/Face Sheet. *All resident Social Data/Face Sheets will be reviewed to assure that the allergy section is completed, as appropriate. *At the time of move in, the Admin. Assist will review all Social Data/Face Sheets and will have the resident/POA provide any missing information. *A final review will be completed by the Dir./Designee to assure that there is no missing information on the Social Data/Face Sheet. Person Responsible: Admin. Assist/Exec. Dir. or Designee Target Date of Completion: 1/25/23 Ongoing
22VAC40-73-680-I
Based on document reviewed and staff interviewed, the facility failed to ensure the medication administration record (MAR) included all required information.
Evidence
  1. On 11-30-22 during medication pass observation with staff #4, resident #1’s November 2022 medication administration record (MAR) did not include a diagnosis, condition, or specific indications for Bumetanide and Potassium Chloride.
Plan of correction
*Resident #1 will have their Physician Order Sheet and MAR updated to include the diagnosis, condition, or specific indications for Bumetanide and Potassium Chloride. *All resident Physician Order Sheets & MARs for Jan. 2023 will be audited by the Health and Wellness Director to identify any that are missing the diagnosis, condition, or specific indications; have them clarified; and then corrected. *The Physician Order Sheets and MARs will be audited during scheduled Nursing Core Checks to assure that all required information is listed. Person Responsible: HWD/Dir. or Designee Target Date of Completion: 1/25/23 & Ongoing
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition for two of six records reviewed.
Evidence
  1. On 11-30-22 resident #1’s record documented resident began receiving hospice services on 7-18-22. The record also documented resident was receiving physical therapy and occupational therapy services, start of services dated 5-26-22. The record documented physical therapy services were discontinued on 7-18-22 and occupational therapy services discontinued on 8-18-22. The ISP was not signed and dated by the facility, resident and/or legal representative to include this review and change in resident’s services (outcome achieved and or discontinued services).
  2. On 11-30-22, resident #2’s record documented occupational therapy services were discontinued on 10-11-22. The ISP was not updated and reviewed to document this change in services.
Plan of correction
*Resident #1 & #2 current Services Plans will be updated to reflect any additional services received by vendors. *Current caseload information will be obtained by any vendors providing services to the residents to assure that all are updated on the current Service Plan and Special Needs List *The Special Needs List will be used to audit Service Plans to assure that the current services are reflected are reflected on the Service Plans. Person Responsible: HWC/Dir./ or Designee Target Date: 1/25/23 & Ongoing
22VAC40-73-450-E
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the license, administrator, or designee (i.e., the person who had developed the plan), and by the resident or resident’s legal representative. The plan should indicate any other individuals who contributed to the development of the plan, with a notation of the date of contribution. The title or relationship to the resident of each person involved in the development of the plan. These requirements shall also apply to reviews and updates of the plan.
Evidence
  1. On 11-30-22, resident #1’s individualized service plan (ISP) signed and dated by facility staff representative on 7-11-22 did not include the signature and date of the resident and/or legal representative.
  2. On 11-30-22, resident #2’s ISP dated 7-8-22 was not signed and dated by the facility, the resident/or legal representative.
  3. On 12-13-22, resident #4’s ISP dated 6-15-22 was not signed and dated by the facility, the resident and/or legal representative.
Plan of correction
*Residents #1, #2, & #4 Service Plans will be reviewed and signed by those designated to sign. *All current Service Plans in the medical records will be checked to assure that each contain the required signatures. When the Service Plans are pending Resident/POA signature, a copy of the email accompanying the Service Plan will be attached to that Service Plan in the chart and tracked for completion by the Admin. Asst. *Ongoing monitoring will take place during routine Nursing Core Checks. Person Responsible: HWC/Exec. Dir./ Admin. Asst. or Designee Target Date: 1/25/23 & Ongoing
22VAC40-73-650-B
Based on record reviewed and staff interviewed, the facility failed to ensure the physician’s order, both written and oral identified the diagnosis, condition or specific conditions for administering for each drug.
Evidence
  1. On 11-30-22, during the medication pass observation with staff #4, resident #2’s November 2022 medication administration record (MAR) and physician’s order dated 10-1-22 did not include diagnosis for the following: Acetaminophen, Diclofenac, Fluticasone, Gabapentin, Lidocaine, Neuriva Plus, Probiotic, Restasis, Benefiber powder, Ibuprofen, Loperamide, Meclizine and Ondansetron.
  2. On 11-30-22, during the medication pass observation with staff #5, resident #6’s November 2022 MAR and physician’s order dated 11-21-22 did not include diagnosis for Timolol.
  3. On 11-30-22 staff #4 and #5 acknowledged the resident’s medication did not include diagnosis.
Plan of correction
*Residents #2 & #6 had their Physician Order Sheets & MARs updated to include a diagnosis for each medication prescribed. *All resident Physician Order Sheets & MARs for Jan. 2023 will be audited by the Health and Wellness Director to identify any that are missing diagnosis and have them clarified and then corrected. *The Physician Order Sheets and MARs will be audited during scheduled Nursing Core Checks to assure that all required information is listed. Person Responsible: HWD/Dir. or Designee Target Date of Completion: 1/25/23 & Ongoing
October 4, 2022Complaint survey3 violations
Inspection dates
10/04/2022, 10/27/2022,11/18/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Complaint An unannounced complaint inspection was conducted on-site on 10-4-22 (ar 9:55/dep 6:00) and 10-27-22 (ar 9:13/dep 5:40) 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 9-29-22 regarding allegations in the resident care/abuse. Number of residents present at the facility at the beginning of the inspection: 63 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: special care unit Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the resident care/abuse of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-470-A
Based on record reviewed and staff interviewed, the facility failed to ensure it either directly or indirectly, the health care services need of a resident was met.
Evidence
  1. On 10-4-22 resident #2’s record included a prescriber’s order dated 7-29-22 for Speech therapy, secondary to cough with eating and to rule out dysphagia. The did not include documentation of service being evaluated.
  2. On 10-27-22, staff acknowledged the record did not include documentation of the speech therapy status.
Plan of correction
*Resident #2 Speech Therapy orders, dated 7-29-22, were referred to CenterWell Home Health for eval. and treat. Per CenterWell, resident #2 Husband did not sign and return consent forms. After multiple attempts, they rejected the referral. *Resident #2 Provider to be consulted regarding current need for SP eval. This will be documented in the medical file. *NCC/ACC to be educated on the need to assure that all orders are carried out, or when appropriate, discontinued by the Provider. *NCC/ACC to be educated on steps to follow when POA consent cannot be obtained. *Two step double check process to be followed with all new vendor orders to assure that all have been carried out, properly documented, and added to the Service Plan as indicated. * Compliance with this requirement will be monitored during Nursing Core-Check audits. Person Responsible: NCC/ACC or Designee
22VAC40-73-450-C
Based on observation, record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs.
Evidence
  1. On 10-4-22, resident #1’s ISP dated 9-7-22 did not include resident’s allergy to Penicillin, information noted in resident’s 9-4-22 visit to the emergency room. The nursing assessment dated 9-7-22 documented the resident is hard of hearing, this information was not on the ISP. Resident’s uniform assessment instrument (UAI) dated 9-7-22 assessed transferring need as mechanical help/the ISP noted transfer with verbal cue but did not document a mechanical device. Eating need assessed as no help/ the ISP documented resident sometimes require staff to feed resident during meals.
  2. Staff acknowledged the ISP did not include all required information.
Plan of correction
*Resident #1 admission History and Physical form, dated 10/18/19, has “Sulfa Antibiotics” listed under allergies by her Provider. The Provider for Resident #1 was contacted for clarification regarding the discrepancy with the drug allergy list provided by them and Sentara Princess Anne Hospital. That clarification was provided on 12/7/22 and shared with the pharmacy for inclusion on the MAR/Physician Order Sheet. This clarification will be maintained in the resident’s medical file. *Resident #1 ISP will be updated to include hearing loss. *Resident #1’s current ability to complete transfers will be updated on the current UAI and Service Plan. *Resident #1 current need for assistance with eating will be evaluated and then updated on the current UAI and Service Plan, as indicated. *Following each UAI and ISP update, both will be audited against each other to assure that they match. Any discrepancies will be clarified and corrected on both documents * Compliance with this requirement will be monitored during Nursing Core-Check audits. Person Responsible: NCC/ACC/DIR or Designee
22VAC40-73-1110-B
Based on record reviewed and staff interviewed, the facility failed to ensure an annual review of the appropriateness of each resident’s continued residence in the special care unit was conducted.
Evidence
  1. On 10-4-22, the last assessment for placement in the special care unit for resident #1 was dated 5-26-21. The resident’s date of admission to the special care unit was dated 11-29-19, also the date of admission to the facility.
  2. On 10-27-22, staff #1 acknowledged the record did not have an update special care unit assessment.
Plan of correction
*Resident #1 has a Review of Appropriate Placement in the medical record dated 5/26/22 *All Memory Care medical records were audited to assure that each contained a current “Review of Appropriate Placement” if indicated. *The NCC, ACC, Dir., CRD or designee assisting a DSS Licensing Inspector will be reminded to also check a resident’s thinned record if a requested form cannot be found in the medical record. *Compliance with this requirement will be monitored during Nursing Core-Check audits. Person Responsible: NCC/ACC or Designee
October 4, 2022Complaint survey1 violation
Inspection dates
10/04/2022,10/27/2022,11/18/2022
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: Complaint An unannounced complaint inspection was conducted on-site on 10-4-22 (ar 9:55 /dep 6:00) and 10-27-22 (ar 9:13/dep 5:40). 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 9-13-22 regarding allegations in the resident care. Number of residents present at the facility at the beginning of the inspection: 63 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: Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of neglect of resident care of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie .barnes@dss.virginia.gov
Violations
22VAC40-73-440-H
Based on record reviewed and staff interviewed, the facility failed to ensure an annual reassessment and reassessment due to a significant change in the resident’s condition, using the uniform assessment instrument (UAI), shall be utilized to determine whether a resident’s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident.
Evidence
  1. On 10-4-22, resident #1’s record did not have a current uniform assessment instrument (UAI). The UAI in the record was dated 8-23-21, the resident’s date of admission was documented as 11-2-19.
  2. On 10-27-22, staff #1 acknowledged the record did not include a current UAI.
Plan of correction
*The most current UAI for resident #1 was completed on 9/7/22 and is in the medical record. *All current resident medical records will be audited to assure that the most current updated/revised resident UAI is in the medical record. *The NCC, ACC, or other identified staff member who has successfully completed UAI training, is to update/revise the UAI in conjunction with updates/revisions to the resident Service Plan. *The NCC, ACC, Dir., CRD or Designee, assisting the DSS Licensing Inspector, will be reminded to also check a resident’s thinned record if a requested form cannot be found in the medical record. *Compliance with this requirement will be monitored during scheduled Nursing Core-Check audits. Person Responsible: NCC/ACC/Dir./Designee
October 4, 2022Complaint survey5 violations
Inspection dates
10/04/2022,10/27/2022,11/18/2022
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Complaint inspection conducted on 10-4-22 (Ar 9:55/dep 18:00) and 10-27-22 (ar 9:13/dep 17:40 p.m). 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 9-27-22 regarding allegations in the area of resident care. 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: 6 Observations by licensing inspector: bed rails, mattress, no oxygen sign on door where Oxygen concentrator located in room with resident with O2 Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-440-H
Based on record reviewed and staff interviewed, the facility failed to ensure an annual reassessment and reassessment due to a significant change in the resident’s condition, using the uniform assessment instrument (UAI) was utilized to determine whether a resident’s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident.
Evidence
  1. On 10-4-22, during a complaint inspection, resident #1’s record did not include an updated or annual reassessment using the UAI. The UAI’s in the record were dated 9-23-20, 10-24-20 and 8-27-21. The resident’s initial date of admission was documented as 10-2-20. The resident was sent out to the emergency room following a fall on 6-30-22 where diagnoses was a broken hip. The resident went to rehabilitation and returned to the facility on 8-2-22. The resident returned with noticeable weight loss and decline. Hospice services was assessed and started 9-22-22.
  2. There was no UAI to include resident’s change in condition and or annual assessment which was also due.
Plan of correction
*Resident #1 was discharged while under Hospice care on 11/1/22. *NCC/ACC/Designee will be re-educated on the situations which trigger a new assessment and the need to revise the UAI and implement a new Service Plan. *All current resident medical records will be audited to assure that the most current updated/revised resident UAI and Service Plan, reflecting any current significant changes, is in the medical record. *The NCC/ACC/DIR/CRD, or Designee, assisting the DSS Licensing Inspector during an inspection, will be reminded to also check a resident’s thinned record if a requested form cannot be found in the medical record. *Compliance with this requirement will be monitored during scheduled Nursing Core-Check audits. Person Responsible: NCC/ACC/DIR/Designee
22VAC40-73-710-C
Based on observation and staff interviewed, the facility failed to ensure if a restraint is used, it must be imposed in accordance with a physician’s written order that specifies the condition, circumstances, and duration under which the restraint is to be used.
Evidence
  1. On 10-4-22, a black cloth, non-traditional bed rail was observed on the right side (window side) of resident #1’s bed. When resident was asked what the rail was used for, the resident was not able to state the use of the bed rail.
  2. Staff acknowledged there was a bed rail in resident #1’s room and attached to the bed, no physician’s order noted in record.
Plan of correction
*Resident #1 POA/son was informed on 9-30-22 that side rails of any kind were not permitted, per the signed acknowledged at the time of move in. Trinity Hospice provided a hospital bed without siderails, on 9-30-22. On 10-5-22, the family was notified that the device they placed on the hospital bed after it was delivered needed to be removed, per policy, and that Trinity Hospice would be lowering the bed and providing fall mats for both sides of the bed. *All resident apartments will be inspected to assure that there are no adaptive devices attached to the bed without an appropriate assessment and Provider orders for that device. *All residents/POA/Responsible Parties will be reminded/notified about the bedrail policy that is signed at the time of admission and asked to not provide any adaptive equipment that must be attached to the bed prior to contacting Nursing or the Director in advance. *Nursing/Housekeeping/ Maintenance will be re-educated on the Branch policy regarding siderails and other adaptive equipment that falls into that category and asked to report any such devices observed in any resident apartments to the NCC/ACC/DIR. *Home Health/Hospice/Rehab providers will also be re-educated on the need to consult with NCC/ACC/DIR prior to attaching any adaptive equipment to a resident’s bed. *Compliance with this will be monitored during routine rounds of resident apartments by Nursing/Housekeeping/ Maintenance/Branch Directors. Person Responsible: NCC/ACC/DIR/Designee
22VAC40-73-700-2
Based on observation and record review, the facility failed to ensure it posted “No-Smoking-Oxygen in Use” sign in any room of a building where oxygen is in use.
Evidence
  1. On 10-4-22, there was not a “No -Smoking-Oxygen-in Use” sign posted on resident #1’s door. The record documented resident prescribed, 2 lpm via nasal cannula, concentrator- prescriber’s order dated 9-22-22.
  2. On 10-4-22 staff acknowledged the required no-smoking sign was not posted for room #306.
Plan of correction
*Resident #1 had a “No Smoking – Oxygen in Use” sign placed on the entrance door on to the apartment on 10/4/22 to alert those entering the apartment that Oxygen was in use. *The Admin. Assist. Made several laminated “No Smoking – Oxygen in use” signs to be hung on any apartment door where Oxygen is in use. Those are located in the main office and at both nurses’ stations *When a new order for Oxygen is received and then delivered by the O2 vendor, the Admin. Asst. or Designated in Charge will ensure that the appropriate signage in hung on that residents apartment door. *Compliance with this requirement will be monitored during scheduled Nursing Core-Check audits. 10/7/22 and ongoing Person Responsible: Admin. Asst./Designated in Charge/NCC/ ACC/DIR
22VAC40-73-450-D
Based on record reviewed and staff interviewed, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated pan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP).
Evidence
  1. On 10-4-22, resident #1’s record documented receiving Skilled nursing services, social worker, chaplain, dietician, and an aide. The ISP dated 9-6-22 did not include these services from the hospice agency.
  2. On 10-4-22 and 10-27-22, staff acknowledged the hospice services were not documented on resident #1’s ISP.
Plan of correction
*Resident #1 was discharged while under Hospice care on 11/1/22. *NCC/ACC/Designee will be re-educated on the situations which trigger a new assessment and the need to revise the UAI and implement a new Service Plan that reflects all services being provided to that resident. *All current resident medical records will be audited, using the current “Special Needs” list, to assure that the Service Plan reflects the most current conditions, care needs, and any provider services addressing those needs. *Compliance with this requirement will be monitored during scheduled Nursing Core-Check audits. Person Responsible: NCC/ACC/DIR/Designee
22VAC40-73-450-C
Based on observation, record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs.
Evidence
  1. On 10-4-22, resident #1’s record documented resident’s wound care services, pressure ulcer to left hip, stage 2. Start of care noted 4-20-22; heel pressure ulcer dated 8-31-22 (right heel – 2 x 3 cm and left heel 3x 3 cm). prescriber’s order for wound care evaluate and treat (necrotic area noted left heel (9-2-22). The hospice nurse’s notation dated 9-22-22 noted a stage 1 on the coccyx area. These services were not documented on the resident’s ISP in the record on 10-4-22. The resident’s ISP noted resident is a high fall risk. A mat was observed on floor (window side) next to the resident’s bed on 10-4-22.
  2. Resident’s record also contained prescriber’s order for PT/OT (physical therapy/occupational therapy) 12/12/21 and 11/23/21. The record did not include documentation of resident receiving therapy services.
Plan of correction
*Resident #1 was discharged while under Hospice care on 11/1/22. *All current resident medical records will be audited, using the current “Special Needs” list, to assure that the Service Plan reflects the most current conditions, care needs, and any provider services addressing those needs. *The NCC/ACC/DIR/CRD, or Designee, assisting the DSS Licensing Inspector during an inspection, will be reminded to also check a resident’s thinned record if a requested form cannot be found in the medical record. *Compliance with this requirement will be monitored during scheduled Nursing Core-Check audits. Person Responsible: NCC/ACC/DIR/Designee
September 8, 2022Complaint survey9 violations
Inspection dates
09/08/2022,10/04/2022,10/27/2022, 11/04/2022,11/18/2022
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: Complaint An on-site complaint inspection was conducted on 9-8-22 (Ar 9:30/dep 14:00), 10-4-22 (Ar 9:55/ dep 18:00) and 10-27-22 (Ar 9:13/ dep 17:40). The facility census was 65 on 9-8-22. Staff and resident interviews were conducted. 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 8-25-22 regarding allegations in the area of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 65 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 6 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 6 Observations by licensing inspector: yes Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes @dss.virginia.gov
Violations
22VAC40-73-610-A
Based on record reviewed and staff interviewed, the facility failed to ensure it honored the food preferences of one of four resident.
Evidence
  1. On 9-8-22, a food preference allegation was conducted. Resident #1’s food preference as noted in the resident’s record documented resident being a picky eater and preferences for hamburgers, pizza, hotdogs and Italian foods. This preference is also noted on the resident’s ISP. The facility “Bread Basket-Scratch Kitchen” menu included items of preference that resident #1 preferred to choose meals. On 9-8-22, a copy of the alternate menu was provided to the inspectors. According to staff #3, the alternate menu was no longer being served, but the staff would prepare the grilled cheese sandwich for resident #1. The resident wanted other items from the alternate menu such as the Bread Basket Burger but could not have items. Staff was asked if the residents were informed that the alternate menu was no longer being served, staff #3 stated residents were not informed of the change.
  2. Staff #3 acknowledged the resident’s preference was not honored due to the menu items not being served as noted when the resident was first admitted on 12-23-19.
Plan of correction
Staff #3 to meet with resident #1 to assure that his meal preferences are updated and properly documented on the Meal Notification form. *Staff #3 to implement the “Daily Fare” menu, 1 item per week, until all Bickford options are available. Those menus will be posted, as planned, and any substitutes or deletions will be posted and communicated to the residents. *Menu preferences will continue to be open for discussion at the monthly Resident Council Meetings, conducted by the LEC. Staff #3 will be invited to participate in those meetings when needed. *The utilization of the “Daily Fare” menus will be monitored during daily rounds. 12/31/22 and ongoing Person Responsible: KM/CRD/LEC/DIR/ or Designee
22VAC40-73-680-I
Based on document reviewed and staff interviewed, the facility failed to ensure the medication administration record (MAR) included all required information for one of four records reviewed.
Evidence
  1. On 9-8-22, resident #2’s June and July 2022’s medication administration record (MAR) did not include the diagnosis, condition, or specific indications for administering the following drug or supplement: Calcium Carbonate, Carvedilol, Digoxin, Donepezil, Eliquis, Entresto, Furosemide, Levetiracetam, L-Lysine, Loperamide, Oxcarbazepine, Restasis, Sertraline, Spironolactone, Thera-M, Vitamin D and C.
  2. Staff acknowledged the MAR did not include the diagnosis for the prescribed drugs and supplements.
Plan of correction
*Resident #2 Physician Order Sheets were audited to assure that all current medications have a diagnosis, condition, or specific indications for taking each medication. *All resident Physician Order Sheets were audited to assure that all current medications have a diagnosis, condition, or specific indications for taking each medication. *All admission orders and new orders will be reviewed prior to profiling to assure that they include all required information prior to being submitted to the pharmacy to be profiled. Once those orders are profiled, the NCC/ACC will review and approve in QuickMar to assure that all orders were entered correctly and contain the correct information. *This will be audited weekly by the NCC/ACC during scheduled medication audits and by the 10th of each month by the Director 12/19/22 and onging Person Responsible: NCC/ACC/DIR/Divisional Nurse/ or Designee
22VAC40-73-460-H
Based on document reviewed and staff interviewed, the facility failed to ensure that personal assistance and care was provided to a resident so that needs of the resident was met.
Evidence
  1. On 9-8-22 during a complaint allegation regarding resident #1’s catheter care, the record documented on 8-17-22 during the healthcare provider’s visit, the healthcare’s notes documented the following concern: there was a lot of pus around SPT site. It was very red and irritated. Needs to be cleaned and kept dry. New orders to empty catheter bag when it is half full- Do not let it get any fuller- make sure catheter is anchored to patient and not hanging¬. Make sure SPT site stays clean and dry. The individual service plan (ISP) dated 14-14-21 documented staff to provide catheter care: empty bag three times a day on each shift, provide catheter care provided by BFM Care staff/problems to be reported to RNC/ACC by care staff and skin integrity to remain intact.
  2. On 10-27-22- Staff’s training record reviewed did not document when staff members received catheter training.
  3. On 10-27-22, staff #1 was not able to determine when facility staff members were provided training on catheter care.
Plan of correction
catheter care and drainage bag maintenance profiled on QuickMar so that the RMAs will be prompted to complete those tasks as ordered. *Nursing BFMs, responsible for catheter care, to receive documented training demonstrating competency with catheter care. *NCC/ACC responsible to assure that the staff working with those residents with special needs have the training required to meet their care needs. This training will be documented. 12/19/22 and ongoing Person Responsible: NCC/ACC or Designee
22VAC40-73-320-B
Based on record reviewed and staff interviewed, the facility failed to ensure a risk assessment was completed annually for tuberculosis (TB) as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it for two of four records reviewed. Evidence:
  2. On 9-8-22, the TB screening in resident #1’s and #2’s record was dated 5-26-21.
  3. Staff #1 acknowledged the residents’ TB were not updated.
Plan of correction
*Resident’s #1 & #2 had their annual TB screenings completed using the VA Dept. of Health screening form or one consistent with it on 11/18/22 *All resident records were audited to assure that those requiring an annual TB screening have one on file. *A binder will be utilized, with tabs by month, to both organize and track which residents have their annual TB screenings due each month. *The NCC/ACC will ensure that they are completed monthly by the Provider prior to their due date. *The NCC, ACC, Dir., CRD or designee assisting a DSS Licensing Inspector will be reminded to also check a resident’s thinned record if a requested form cannot be found in the medical record. *Compliance with this requirement will be monitored by the Dir. monthly and during scheduled Nursing Core-Check audits. 11/28/22 and ongoing Person Responsible: NCC/ACC/DIR or Designess
22VAC40-73-325-B
Based on record reviewed and staff interviewed, the facility failed to ensure a fall rating was completed after a resident’s fall for one of four records reviewed.
Evidence
  1. 0n 9-8-22, resident #3’s progress notes documented on 8-10-22 (07:30) resident was found on floor, resident refused to go to ER; abrasion noted on right cheek (ice applied); contusion on chin, and contusion to right fingers. The record did not include documentation of a risk rating.
  2. Staff acknowledged the record did not include a risk rating following the resident’s fall.
Plan of correction
*Resident #3 had a Fall Risk Investigation Tool completed to assure that there is a current rating in her file. *Any existing residents who’ve had a fall since their Admission, Annual, or Significant Change Assessment will also have a Fall Risk Investigation Tool completed to assure that there is a current risk rating in their medical record. *NCC/ACC/Designee to be educated on the requirements of this form to include what triggers the need for a new fall risk assessment. *Post fall documentation will include a completed Fall Risk Investigation Tool to be reviewed, signed by the Director/Designee, and placed in the resident’s medical record. *The NCC, ACC, Dir., CRD or Designee assisting a DSS Licensing Inspector will be reminded to also check a resident’s thinned record if a requested form cannot be found in the medical record. * Compliance with this requirement will be monitored by the Dir. monthly and during scheduled Nursing Core-Check audits. 12/31/22 and ongoing Person Responsible: NCC/ACC/DIR/Or Designee
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for four of four records reviewed.
Evidence
  1. On 9-8-22 resident #1’s individualized service plan (ISP) dated 12-14-21 (end date 6/2022) did not include the resident’s Speech therapy services. The record included services for cognition/short-term memory/problem solving concerns dated 12-8-21 to 1-5-22. Physical therapy services not included on the ISP; service dates: 1-2-22 to 3-17-22 and 3-18-22 to 5-21-22. The uniformed assessment instrument (UAI) dated 12-14-21 assessed wheeling and stairclimbing as not performed; these areas were not included on the ISP. Bathing need assessed on UAI as mechanical help/supervision; the ISP did not include supervision.
  2. Resident #2’s ISP dated 1-12-22 and 5-24-22 did not include the resident’s Speech therapy (2-2-22 to 6-7-22 and 6-8-22 to 9-5-22), Occupational Therapy (1-31-22 to 4-30-22, 5-1-22 to 7-29-22 and 7-30-22 to 9-27-22) and Physical Therapy (1-19-21 to 4-18-22, 4-19-22 to 7-17-22 and 7-18-22 to 9-30-22). The resident’s pacemaker noted on the resident’s physical dated 12-13-19 was not documented on the ISP.
  3. Resident #3’s uniformed assessment instrument (UAI) dated 7-20-22, mobility assessed as mechanical help/physical assistance, this need was not on the ISP dated 7-20-22.
  4. Resident #4’s ISP dated 11-29-21 and 6-30-22 did not include the resident’s Physical therapy services (2-11-22 to 5-27-22).
  5. Staff acknowledged the ISPs for the aforementioned residents did not include all assessed needs.
Plan of correction
*Resident #1 Service Plan to be updated to reflect most current Speech & Physical Therapy treatment plans summary, visit schedule, goals, and achievement dates once reached. The most current ISP/UAI will be reviewed to assure that identified care needs and abilities match on both documents. *Resident #2 Service Plan to be updated to reflect the most current Speech & Occupational Therapy treatment plans summary, visit schedule, goals and achievement dates once reached. The pacemaker, referenced on the Physical form, will be added to the Service Plan and noted on the UAI. *Resident #3 most current ISP/UAI will be reviewed to assure that identified care needs and abilities match on both documents to include mobility. *Resident #4 Service Plan to be updated to reflect the most current Physical Therapy treatment plans summary, visit schedule, goals and achievement dates once reached. 12/19/22 and ongoing Person Responsible: NCC/ACC/DIR/ or Designee
22VAC40-73-310-H
Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals in the assisted living with any conditions or care need prohibited by the regulation and Code of Virginia for one of four records reviewed.
Evidence
  1. On 9-8-22, resident #1’s medication administration record for September 2022 documented resident is prescribed Celexa. The record did not have documentation of a psychotropic treatment plan.
  2. Staff acknowledged catheter care not completed.
Plan of correction
*Resident #1 provider will be contacted and a Psychoactive Treatment Plan obtained for the Celexa. *A list of Psychoactive Medications will be used to audit against all resident Physician Order Sheets to identify any other prescribed Psychoactive Medications to assure that each has the required Treatment Plan in the medical record or thinned chart. *The Psychoactive Treatment Plan order forms were added to the Provider’s binders who make visits in the Branch to see their patients. For those residents with Community Based Providers, the Psychoactive Treatment Plan order forms will be added to the envelope of information that residents take to their medical appointments. *The NCC, ACC, Dir., CRD or designee assisting a DSS Licensing Inspector will be reminded to also check a resident’s thinned record if a requested form cannot be found in the medical record. *Compliance with this requirement will be monitored during the routine weekly medication audits conducted by Nursing and during Nursing Core-Check audits. Person Responsible NCC/ACC and Dir.
22VAC40-73-390-A
Based on documents provided and policy provided, the facility failed to ensure when there was an increase in charges, the resident/legal representative would be provided advanced notice of intent to increase charges for four of four records reviewed.
Evidence
  1. On 9-8-22, in response to a complaint allegation of services being bill and notification not provided, a request of residents’ bills and notification information was requested.
  2. A billing statement was provided for residents #1, #2, #3 and #4. The request for notification was not provided.
  3. On 10-04-22, the request for documentation of notification of rate increases to residents was to the staff #1. Staff #1 was not able to provide documentation of rate increase notices to residents and/or legal representative.
  4. On 11-4-22, a copy of the facility’s was received noted in Section IV.B (Rent, Fees and Deposits) noted, thirty (30) day written notice is not required if there is a change in the level of care charges pursuant to the Resident Service Assessment and Rate matrix. A change in level of care charges pursuant to the Resident Service Agreement and Rate Matrix will become effective upon notice to the Resident or Resident’s Representative. The record did not have documentation of changes in the residents’ service agreement since admission, the initial agreement upon admit to the facility. The record did not include any amendments to the initial agreement.
  5. The facility’s Change in Level of Care (VA)-PP-60450 policy noted 1.f- the Resident Admission Agreement will be updated as appropriate. The document also not 1.e- a resident had the right to appeal the outcome of the assessment, reassessment, or determination of level of care.
  6. Resident #1’s Individual Service Plan (ISP) was signed and dated by the representative 12-14-21. The Resident Agreement in the record is dated 12-3-19. Resident #2’s ISP is signed and dated 1-12-22, the resident agreement is dated 12-23-19. Resident #3’s ISP is noted as 180-day assessment (7-20-22), there is not facility staff signature or date and not resident or representative signature. The resident agreement is signed and dated 6-11-20. Resident #4’s 180-day assessment (6-30-22), no signature by facility staff and no resident/representative signature. The Resident agreement is signed and dated 12-5-19.
  7. Staff #1 acknowledged on 10-4-22 and 10-27-22, the record does not include documentation of rate increase notices to the resident and/or representative. Staff #1 stated the increase is provided during assessment review with the resident/family. The reviews in the record are not signed and dated by the resident/or representative.
Plan of correction
*Residents #1, #2, #3, & #4 have a copy of the most current annual increase letter in their file. *Residents #1 & #2 financial POA has participated in email/text/verbal/in person conversations about the charges of #1 & #2, which are also clearly displayed, by resident per day, on the monthly invoices mailed to the financial POA monthly. The Director will arrange to have additional explanation provided so that all charges can be comprehended and understood by the financial POA. That documentation will be maintained in the resident’s Admin. file. *All current resident’s Admin. files will contain a copy of all annual rate increase letters mailed to the address of record for each resident. Those residents who receive a change in their level of care charges will have the revised Service Plan emailed to the address of record, as an attachment, with the change in fees included in the body of the email. A copy of that email will be filed in the resident’s Admin. file. *Resident Admin. files will be audited for compliance during schedule Core-Check audits. 12/19/22 and ongoing Person Responsible: DIR/ADMIN ASST/ or Designee
22VAC40-73-710-C
Based on observation and staff interviewed, the facility failed to ensure when a restraint is used, the requirements for usage was completed.
Evidence
  1. On 9-8-22, a U-bar was observed attached to resident #2’s bed. The record did not have documentation for the use of a U-bar. There was no documentation on the individualized service plan and no physician’s order specifying the condition, circumstances, and duration under which the restraint was to be used.
  2. On 10-27-22, staff #1 acknowledged the record did not contain documentation for resident #1’s U-bar and there was no written physician’s order for this restraint.
Plan of correction
*Resident #2 therapy providers, Fox Rehab, have been contacted regarding the U-Bar to determine if it is still needed or if it can be removed. That information will be shared with the Provider and then updated on the UAI and Service Plan. *All resident apartments will be inspected to assure that there are no adaptive devices attached to the bed without an appropriate assessment and Provider orders for that device. *All residents/POA/Responsible Parties will be reminded/notified about the “bedrail policy” that is signed at the time of admission and asked to not provide any adaptive equipment that must be attached to the bed prior to contacting Nursing or the Director in advance. *Nursing/Housekeeping/ Maintenance will be re-educated on the Branch policy regarding siderails and other adaptive equipment that falls into that category and asked to report any such devices observed in any resident apartments. *Home Health/Hospice/Rehab providers will also be re-educated on the need to consult with Nursing or the Director prior to attaching any adaptive equipment to a resident’s bed. *Compliance with this will be monitored during routine rounds of resident apartments by Nursing/Housekeeping/ Maintenance/Branch Directors 12/19/22 and ongoing Person Responsible: NCC/ACC/DIR/or Designee
August 18, 2022Complaint survey18 violations
Inspection dates
08/18/2022,08/22/2022,08/29/2022,09/02/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Complaint On-site renewal inspection conducted two days, 8-18-18 (two inspectors from ERO/PLO) (Ar 08:10 /dep 6:25 p.m.) Day 2 on 8-22-22 one inspector (Ar 10:20 a.m./dep 6:00 p.m.)The facility census was 62, a tour of the facility was conducted, medication pass observation, activity, emergency preparedness/ first aid kit check, resident and staff records and interviews conducted. A preliminary exit conducted with administrator and two other staff members. The Acknowledgement Form was signed and dated. Requested documents requested and received via email. Preliminary exit and review conducted on 8-22-22 with administrator and staff member. Acknowledgement Form signed and dated. Request for additional documents requested and received via email. Third preliminary meeting conducted virtually on 8-29-22 with administrator and Nursing Services Director. Final exit interview will be conducted. The Acknowledgement of Inspection form was sent to the Administrator following each exit meeting and receipt of documents. 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. 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 (Willie Barnes), Licensing Inspector at (757-439-6815) or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-580-D
Based on record review and staff interviewed, the facility failed to ensure when the uniformed assessment instrument (UAI) assessed resident as dependent in eating/feeding, the individualized service plan (SIP) shall indicate an approximate amount of time needed for meals to ensure needs are met.
Evidence
  1. On 8-22-22, resident #10’s uniformed assessment instrument (UAI) dated 4-28-22 documented resident is fed by others. The individualized service plan (ISP) 5-22-22 did not document an approximate amount of time needed for meals to ensure resident’s needs are met.
  2. On 8-22-22 and 8-29-22, staff #1 acknowledged the aforementioned resident’s record did not document amount of time need to assist resident with meals.
Plan of correction
*Resident #10 to be evaluated during mealtime to determine the approximate amount of time required to consume meals to ensure that resident needs are met. Input will also be obtained from those staff members who assist this resident at mealtime. This information will be added to the service plan *Any other residents identified as needing to be fed will also be assessed to determine the approximate time required to eat during mealtimes. That information will be added to their service plans. *SP therapy will also be consulted when any identified residents are receiving those ser * Nursing Core Checks and ISP audits to be conducted, as a part of our Quality Assurance process, to assure that all residents identified as needing feeding assistance have the approximate amount of time needed to eat during meals documented on their service plans.
22VAC40-73-440-H
Based on record review and staff interviewed, the facility failed to ensure an annual reassessment, using the uniformed assessment instrument (UAI), shall be utilized to determine whether a resident’s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident.
Evidence
  1. On 8-18-22, resident #3’s record’s uniformed assessment instrument (UAI) was dated 10-2- 20 and 10-26-20. The resident’s date of admit was documented as 10-12-20.
  2. On 8-18-22, resident #5’s record did not have a copy of the UAI, resident’s date of admit documented as 8-26-21.
  3. On 8-18-22, staff #1 acknowledged the aforementioned resident did not have an annual reassessment using the UAI.
Plan of correction
*Resident #3 UAI dated 9/22/21 reassessment was retrieved from the thinned chart and placed in the medical record. *Resident #5 UAI dated 8/10/21 assessment and 9/1/21 reassessment was retrieved from the thinned chart and placed in the medical record. *Resident #1 was admitted on 11/1/21. UAI dated 10/21/21 assessment was retrieved from the thinned chart and placed in the medical record. *100% audit of all resident records will be conducted to assure that the initial UAI assessment and most current UAI reassessment are located on the medical record. *Nursing Core Checks to be conducted, as a part of our Quality Assurance process, to assure that all original UAI assessments and most current UAI reassessments remain in the medical record. Person Responsible: NCC/ACC/Dir./Divisional Nurse
22VAC40-73-40-B-8
Based on observation and staff interviewed, the facility failed to current license was posted in the facility.
Evidence
  1. On 8-18-22, during a tour of the facility, the current license was posted. The license posted expired May 11, 2022.
  2. On 8-18-22, staff #1 acknowledged the current license was not posted in the facility.
Plan of correction
*The expired license, dated 5/11/22, was re-issued by DSS on 8/9/22 and emailed to the licensee on 8/10/22. *The electronic copy was printed and then photocopied onto cardstock and hung at the entryway of the Branch on the morning of 8/18/22 prior to the exit of this monitoring inspection. *The posted license will be checked, during daily rounds, to assure that the most current copy is hanging and on display. Person Responsible: Dir/ Admin. Asst
22VAC40-90-40-B
Based on record reviewed and staff interviewed, the facility failed to ensure that private duty personnel had an original criminal history record report issued by the Virginia Department of State Police, Central Criminal Records Exchange for each private duty personnel.
Evidence
  1. On 8-22-22 a review of the private duty staff #11 and #12’s records with staff #1, there was no documentation of a criminal history report reviewed and /or in the record.
  2. Staff #1 acknowledged not having a criminal history record for the aforementioned private duty staff.
Plan of correction
*CS-1 had a Criminal Background Check completed on 8/23/22. There was no conviction data. *CS-2 had a Criminal Background Check completed on 8/22/22. There was no conviction data. *Both agencies providing the services of CS-1 and CS-2 were provided with a copy of Standard 22VAC73-220 for ongoing compliance purposes. *All resident and family members will receive, at the time of move in, written guidelines of the requirement to provide notification to the Branch, in advance, of the desire to employee the services of a private duty companion to assure that all regulatory requirements are met. Person Responsible: Dir./Admin. Asst.
22VAC40-73-290-B
Based on observation and staff interviewed, the facility failed to ensure it posted the name of the current on-site person in charge.
Evidence
  1. On 8-18-22, the name of the current on-site person in charge was not posted in the facility. There was also no posting of the previous shifts (11p- 7a). This inspector had on previous inspection reminded staff #1 of the requirement for posting the staff person in charge (4-7-22 and 2-7-22).
  2. Staff #1 acknowledged the facility did not post the name of the current on-site person in charge.
Plan of correction
*A framed sign, with the names and titles of the 4 members of the Directing Family Group, will be conspicuously displayed to the residents and the public on the table at the entry way in the Branch and will include the name and title of the current on-site person in charge, on each shift. *This will be scheduled to be updated weekly, and any changes will be notated. *These signs will be kept on file with the corresponding schedule that also indicates whomever is in charge at any given time. Person Responsible: Dir./Admin. Asst./Designee
22VAC40-73-1180-B
Based on observation and staff interviewed, the facility failed to ensure that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident’s on the safe, secure unit, except under staff supervision.
Evidence
  1. On 8-18-22 during a tour of the safe, secure unit with staff #5, two air blowing machines were observed in two chairs in the hallway. There was no supervision of these electrical items.
  2. Staff #5 acknowledged the items should not have been left unsupervised on the safe, secure unit.
Plan of correction
*The two carpet drying enclosed fan units observed in the chairs on the safe, secure unit were put away. *The Maintenance Coordinator was instructed to put all carpet care equipment away when not in use. *ACC and care staff instructed to always be on the lookout for any items that could pose potential harm on a safe, secure unit and to report any observations to the Maintenance Coordinator and/or Director. Person Responsible: Maintenance Coord./ACC/Care Staff
22VAC40-73-660-A
Based on observation and staff interviewed, the facility failed to ensure medications were stored in a manner consistent with current standards of practice.
Evidence
  1. On 8-18-22, during a tour of the facility, resident #7 and #8’s medications on the safe, secure unit were observed unsecured on a desk in the common area. Staff #3, the medication person, was present and the inspectors spoke with staff regarding what was observed. Staff then went into the medication room but did not take the two containers of multiple medication cards into the medication room.
  2. On 8-18-22, staff #3 acknowledged the medications on the safe, secure unit for two residents assigned to the 300 hallway were not properly stored on the morning of 8-18-22.
Plan of correction
*Staff #3 to receive additional education on the proper storage procedures for all medications in an Assisted Living Community with emphasis on the additional safety concerns on a safe, secure unit. *This occurrence will be documented. *Staff #3 to receive a med pass observation to ensure that all proper procedures are being followed with regards to proper medication administration procedures. Person Responsible: NCC/Divisional Nurse/appropriate designee
22VAC40-73-680-M
Based on observation and staff interviewed, the facility failed to ensure medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. On 8-18-22 during the medication pass observation with staff #4, the following resident's PRN medications were not available in the facility: resident #4’s Bisacodyl and Glucagon kit.
  2. Staff #4 acknowledged the aforementioned residents’ PRN medications were not available on 8-18-22.
Plan of correction
*Resident #4 Glucagon kit and Bisacodyl refill requested on 8/18/2022 *100% audit of all residents with PRN medication orders to assure that all of the medications are on hand and able to be given if requested. *Ongoing monitoring during weekly medication variance audits and MAR/POS audits. Person Responsible: NCC/ACC/designee
22VAC40-73-220-A
Based on documents reviewed and staff interviewed, the facility failed to ensure before direct care or companion services are initiated, the facility shall obtain, in writing, information on the type and frequency of the services to be delivered to the residents by the private duty personnel, review the information to determine if it is acceptable, and provide notification to home care organization or whomever is hired regarding any needed changes. The services should be reflected on the resident’s individualized service plan. The facility shall provide orientation and training to private duty personnel regarding facility policies and procedures related to private duty personnel and documentation of resident care required ismaintained.
Evidence
  1. On 8-22-22, a review of CS-1’s record did not have documentation of the required information for private duty personnel. There was no documentation of orientation, description of services and frequency and no documentation of facility policies and procedures relating to private duty personnel.
  2. On 8-22-22, staff #1 stated private sitter provides services for residents #12 and #13. Individual hired by the family.
  3. On 8-22-22, staff #1 stated CS-2 also provided sitter duties in the facility, but staff did not know which resident received the services. Individual hired by a private agency.
  4. On. 8-22-22, staff #1 acknowledged private duty personnel were providing services in the facility and the facility did not have the required documentations.
Plan of correction
*CS-1 was a former nursing staff member of Bickford of Virginia Beach and completed orientation at the time of hire on 10/07/2019 and again on 1/11/22 as a private duty companion. CS-2 is employed by a licensed and JCAHO accredited staffing agency in the state of VA. She received orientation on 9-14-22 *Both CS-1 and CS-2 provided their frequency and description of companion-only services on 8/22/22. *Both agencies providing the services of CS-1 and CS-2 were provided with a copy of Standard 22VAC73-220 for ongoing compliance purposes. *All resident and family members will receive, at the time of move in, written guidelines of the requirement to provide notification to the Branch, in advance, of the desire to employee the services of a private duty companion to assure that all regulatory requirements are met. Person Responsible: Dir./CRD/Admin. Asst.
22VAC40-73-470-A
Based on record reviewed and staff interviewed, the facility failed to ensure directly or indirectly, that the health care service needs of a resident was met.
Evidence
  1. On 8-22-22, resident #11’s record included a signed physician’s order dated 7-1-22 for speech therapy to evaluate for dysphagia.
  2. Staff acknowledged the order for the aforementioned resident’s speech services was not conducted.
Plan of correction
*Resident #11 medical record contains the SP initial evaluation and therapy notes ordered by the provider on 7/1/2022. *In-house rehab provider to generate documentation for all residents currently receiving therapy services that will be kept in a separate file that is easily assessable by Bickford staff. *The weekly rehab caseload report will be used for audit purposes to assure that documentation for all services is on site and available. Person Responsible: NCC/ACC/Dir./Divisional Nurse
22VAC40-73-260-C
Based on observation and staff interviewed, the facility failed to ensure the listing of all staff certified in current first aid and CPR was kept up to date.
Evidence
  1. On 8-18-22, staff #4 was asked where the facility’s first aid/CPR listing was posting. A check of the listing on the wall in the medication room, determined the list was not current. A more current listing was located in staff information binder at the nursing station. Review of the document revealed there staff names with expired certification (6-9-22 and 1- 2022).
  2. Staff #4 acknowledged the first aid/CPR listing was not updated.
Plan of correction
*All staff records were audited to determine current CPR/First Aid training status. *A revised current list of those staff with current CPR/First Aid training was posted on the AL Nurses Station bulletin board, in the Communication Binder at the AL Nurses Station and in the Main Office on the Training Bulletin Board. *CPR/First Aid training was conducted on 9/7/22 and is also scheduled for 9/30/22. The list will be updated following that training. *The Admin. Asst. has scheduled that the list be updated every month, on/around the 15th, to assure that only those with current certification are posted Person Responsible: Dir./Admin. Asst./Designee
22VAC40-73-250-D
Based on document reviewed and staff interviewed, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility shall submit the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as
Evidence
  1. s by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. On 8-22-22, CS-1 and CS-2 record did not have documentation of the results of a risk assessment, documenting the absence of tuberculosis (TB) 2 .On 8-22-22, staff #3’s TB was dated 6-4-22. Staff’s date of hire was documented as 5-31-22.
  3. On 8-29-22, staff #1 acknowledged the TB information were not completed as required per the requirements.
Plan of correction
*CS-1 completed TB testing on 9/26/19, 8/4/21, and again on 8/27/22 and was negative. CS-2 completed a TB screening on 6/28/22 and was negative. *All resident and family members will receive, at the time of move in, written guidelines of the requirement to provide notification to the Branch, in advance, of the desire to employee the services of a private duty companion to assure that all regulatory requirements are met. *Staff #3 completed TB testing on 6/4/22 during her scheduled orientation and prior to assuming responsibility for her position. *All applicants will complete TB testing or a TB Risk Assessment within 7 days prior to their actual “start date” in the Branch and will not participate in any orientation activities “on-site” in the Branch until negative TB/Risk Assessment results are received. *All staff records will be audited to assure that each contains a current negative TB Risk Assessment/Screening or negative TB results. Person Responsible: Dir./Admin. Asst.
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for six residents’ record.
Evidence
  1. On 8-18-22, resident #1’s record documented resident’s allergy to some chocolate and not to others. The physical dated 10-28-21documented resident’s hearing loss. The uniformed assessment instrument (UAI) noted resident’s use of eye glasses, resident also observed with eye glasses. The UAI transferring need assessed as “mechanical help”. The record included a physician signed and dated (10-28-21) Do Not Resuscitate (DNR) document. These were not documented on resident’s ISP dated 1-19-22.
  2. On 8-18-22, resident #2’s UAI dated 6-30-22, toileting need assessed as ‘human help/supervision”, the ISP documented use of grab-bar, walker and raised toilet seat. Mobility need assessed as “mechanical help” use of walker. This need was not documented on the ISP dated 6-30-22.
  3. On 8-18-22, resident 3’s ISP dated 2-16-22 did not include resident mental health services being provided by a local agency.
  4. On 8-18-22 and 8-22-22, resident #4’s UAI dated 6-30-22, stairclimbing need assessed as “mechanical help”. Resident assessed as “disoriented sometime” to time. The record also documented mental health services being provided by a local agency (7-5-22). Occupational therapy, physical therapy and speech therapy (start 5-26-22 to 7-24-22) documented in record. Resident also observed wearing eyeglasses. These needs were not documented on the ISP dated 6-30-22. The ISP documented resident code as “Do Not Resuscitate”, the record did not include a signed and dated physician’s DNR order.
  5. On 8-22-22, resident #8’s record documented physical therapy services for cellulitis, right lower limb (5-28-22 to 7-26-22, recertification 7-26-22 to 9-24-22). This need was not documented on the ISP dated 6-30-22.
  6. On 8-22-22, resident #9’s UAI dated 1-12-22, transferring assessed as not help needed. The ISP dated 2-8-22 documented need as “mechanical help needed”, use of walker and arm rest. Stairclimbing need assessed as “not performed”, however, the ISP did not document how and need would be provided. The signed physician’s orders (POS) documented allergy to Codeine, Gabapentin, Hydrocodone, Oxycodone and stimulant laxative. Physical therapy services notes dated 2-16-22 to 5-19-22 (discharged note 5-19-22), skilled nursing order (1-20-22 to 3-20-22) and mental health services (notes 3-22-22 to 8-16- 22) from a local agency. These needs were not documented on the ISP dated 2-28-22.
  7. On 8-18-22 and 8-22-22, staff #1 acknowledged the aforementioned residents’ UAI and ISP did not include all assessed/identified needs.
Plan of correction
Not published by VDSS.
22VAC40-73-550-G
Based on record reviewed and staff interviewed, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual.
Evidence
  1. of this review shall be in the resident’s, his legal representative’s or responsible individual’s written acknowledgement of having been so informed, which shall include the date of the review and shall be filed in the resident’s record. Evidence: 1.On 8-18-22 and 8-22-22, the following residents’ record did not have documentation of an annual review of the resident’s rights and responsibilities: residents’ #2, #3, #4, #5, #6, #7, #8 and #10.
  2. On 8-22-22, staff #7, acknowledged the residents’ rights and responsibilities were not signed and dated and place in residents’ record.
Plan of correction
*Residents #2, #3, #4, #5, #6, #7, #8, & #10 will have their annual resident rights review completed and documented with them, or their POA when indicated, prior to 9/30/2022. *All remaining residents will also have their annual resident rights review completed and documented with them, or their POA when indicated, prior to 9/30/2022. *The annual resident rights review will be scheduled yearly in September to assure that it is conducted annually. *The documentation will be maintained in the Admin. office in the Resident Rights Annual Review binder. Person Responsible: LEC/LEA/Designee
22VAC40-73-680-B
Based on observation and staff interviewed, the facility failed to ensure medications was remained in the pharmacy issued container, with the prescription label or direction attached, until administered to the resident.
Evidence
  1. On 8-18-22, upon approaching the medication cart on the safe, secure unit, the inspectors observed four medication cups with medications on top of the medication cart. Staff #3 was inquired regarding the medications and stated the medications were for four residents on the 300 hallway who do not reside on the safe, secure unit. The medication staff on the safe, secure unit is responsible for administering medication on the 300 hallway located off the unit. The medications that were pre-poured were for residents #1, #5, #7 and #8. On 8-18--22 staff #3 acknowledged preparing the medications beforehand to administer later to the residents located on the 300 hallway.
Plan of correction
* Staff #3 to receive additional education on the proper administration of medications with emphasis on the importance of not pre-pouring medications. *This occurrence will be documented. *Staff #3 to receive a med pass observation to ensure that all proper procedures are being followed with regards to proper medication administration procedures. Person Responsible: NCC/Divisional Nurse/appropriate designee
22VAC40-73-680-K
Based on observation and staff interviewed, the facility failed to ensure medications order shall have the exact dosage.
Evidence
  1. On 8-18-22 during the medication pass observation with staff #4, the following resident’s medication label and August 2022 medication administration record (MAR) documented medications without exact dosages: (1) resident #4’s Metamucil noted 4 ounces of fluid, the label noted at least 8 ounces and (2) resident #9’s Miralax noted give 4 to 8 ounces fluid.
  2. Staff #1 acknowledged the aforementioned residents’ medication did not have the exact dosage of liquid, but was noted to have a range of fluid ounces for the mixtures.
Plan of correction
*Resident #4 to receive a clarification order with regards to the fluid ounces to be used while administering Metamucil. *Resident #9 to receive a clarification order with regards to the exact amount of fluid ounces to be used while administering Miralax. *100% audit of all residents taking Metamucil, Miralax or other medications to be mixed with fluids to assure that each set of instructions include the exact amount of fluid ounces to be used while administering those medications. *All new orders for medications to be administered with fluids to be reviewed by the NCC/ACC to assure that the instructions are clear with the proper and exact amount of fluid ounces to be used. *Ongoing monitoring during weekly medication variance audits and MAR/POS audits. Person Responsible: NCC/ACC/designee
22VAC40-73-960-C
Based on observation and staff interviewed, the facility failed to ensure the emergency telephone numbers for poison control center shall be posted by each telephone shown on the fire and emergency evacuation plan.
Evidence
  1. On 8-18-22, the emergency telephone numbers were not observed posted near the telephones and not in the facility’s binder of telephones numbers to call in the event of an emergency.
  2. Staff #1 acknowledged the emergency telephone numbers required to be posted or near the telephones were not available on the day the inspectors were present.
Plan of correction
*Required emergency telephone numbers were posted on each of the new telephones received and installed in April 2022 on 9/12/2022 *Any new or additional telephone equipment, identified on the fire and emergency evacuation plan, will have the emergency telephone numbers posted on/near them, as required. Person Responsible: Admin. Asst./designee
22VAC40-73-450-E
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan was signed and dated by the resident and/or legal representative.
Evidence
  1. On 8-22-22, resident #11’s comprehensive service plan (ISP) dated 7-29-22 was not signed and dated by the resident and/or his legal representative.
  2. On 8-22-22, staff #1 acknowledged the aforementioned resident’s service plan was not signed.
Plan of correction
*Resident #11 Service Plan, completed on 7/29/22, emailed to the daughter on 9/14/22 for signature. *100% audit of all resident records to be conducted to assure that either a signature or email confirmation of receipt is received for all resident service plans. *NCC/ACC, upon completion of the ISP, is to give it to the Admin. Asst. to obtain the Director’s signature and then obtain residents signature and/or email to POA for signature. Also to schedule a care plan meeting, when requested. Upon receiving the signed copy, the original is to be filed in the medical record, and a copy is to be filed in the Life Song Binder *Nursing Core Checks and routine audits to be conducted, as a part of our Quality Assurance process, to assure that all services plans have the required signatures or documentation of receipt. Person Responsible: NCC/ACC/Dir./Divisional Nurse
April 7, 2022Inspection16 violations
Inspection dates
04/07/2022,04/26/2022,05/04/2022,05/11/2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Renewal On-site renewal inspection was conducted with two inspectors from the Peninsula Licensing Office on 4-7-22 (Ar 07:45 /dep 4:55 p.m). The facility census was 61, a tour of the facility was conducted, medication pass observation, activity, emergency preparedness/ first aid kit check, resident and staff records and interview conducted. A preliminary exit conducted with administrator and assistant resident coordinator on 4-7-22. Requested documents received on 4-26-22, exit and review conducted on 5-4-22 with administrator, nursing coordinator and assistant resident coordinator, final exit interview conducted on 5-11-22 with administrator and nursing coordinator. Final exit interview with renewal inspection documents conducted on 6-6-22. The Acknowledgement of Inspection form was sent to the Administrator following each exit meeting and receipt of documents. 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. 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 (Willie Barnes), Licensing Inspector at (757-439-6815) or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for six of nine residents.
Evidence
  1. On 4-7-22, resident #1’s record did not include documentation of a comprehensive individualized service plan (ISP). The record include a preliminary plan of care completed 1-17-22 by facility staff #10 and signed by the resident’s legal representative on 2-10-22. The resident’s date of admission to the facility was documented as 2-10-22, facility document Matrix Care- Resident Census, submitted on 5-6-22 resident’s admit change date to facility’s safe, secure unit.
  2. On 4-7-22, resident #2’s record documented resident receiving psychological services from a local agency. Documentation were dated 3-8-22 and 4-5-22. These services were not documented on the resident’s ISP dated 9-23-21. The resident’s April 2022 medication administration record documented resident keeps Systane Gel eye drops and Zicam nasal spray at bedside. The resident’s uniformed assessment instrument (UAI) dated 9-23-21 documented medication administered by facility staff. Resident’s UAI documented wheeling and stairclimbing “not performed: the ISP did not include who would perform services, how and where. The aforementioned services were not documented on the resident’s ISPs dated 9-23-21 and Care Plan dated 3-11-22 (180 day assessment submitted on 5-6-22).
  3. Resident #3’s ISP dated 8-24-21 and 3-18-21 did not include resident’s physical therapy services (4-4-21 and discharged 5-17-21); occupational therapy (4-8-21 and discharged 5-17-21) and speech therapy services (3-31-21 and discharged 5-5-21). Resident’s record included documentation resident wears trifocal eye glasses. This information was not documented on resident’s preliminary ISP dated 2-19-21, ISP dated 3-28-21 and ISP dated 8-24-21.
  4. Resident #4’s ISP dated 8-28-21 did not include resident’s psychological services. The record noted services provided by an agency on 9-20-21 (initial services); additional dates of services documented in the record: 9-28-21; 12-14-21; 1-11-22; 3-8-22 and 4-5-22. The uniformed assessment instrument (UAI) dated 3-23-21 documented wheeling and stairclimbing not performed. The wheeling and stairclimbing needs were not documented on the ISP dated 8-28-21.
  5. Resident #6’s admission physical examination dated 1-13-22 documented the following allergies: Codeine, Gabapentin, Hydrocodone, Oxycodone and stimulant laxative. This information was not documented on the resident’s ISP dated 1-22-22 and 2-10-22.
  6. Resident #9’s record included copy of Do Not Resuscitate (DNR) dated 11-4-21, this information not documented on the ISP.
Plan of correction
*Resident #1 Service Plan, reflecting the level of care change to Assisted Living from MBs is located in the Medical Record. *Resident #9 has been discharged. *Resident’s #2, #3, #4, & #6 Service Plans were updated to include the information/services referenced in this report. *All current resident Service Plans will be modified as care and services are added or updated and during scheduled re-assessments. *This will be monitored during scheduled Core Check audits completed by the Directing Family Group and the results reported for Divisional Review Person Responsible: NCC/ACC or Designee/Dir./Divisional Leadership Target Completion Date:6/30/2022 & ongoing
22VAC40-73-380-B
Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s personal and social information placed in resident’s record was kept current for three of nine records reviewed.
Evidence
  1. On 4-7-22, resident #’1s record included a copy of the resident’s “Do Not Resuscitation (DNR)” document signed and dated 1-24-22 by the physician. The resident’s ISP dated 1-17-22 documented the resident as a “Full Code”. The resident’s personal and social data document also noted resident as a “Full Code”.
  2. On 4-7-22, resident #7’s record included a copy of the resident’s DNR dated 6-17-20. The personal and social data document noted resident as a “Full Code”.
  3. On 4-7-22, staff #1 acknowledged the aforementioned residents’ social data/personal sheet documented- face sheet documented residents as a “Full Code”.
Plan of correction
*Resident #1 had the code status updated on the Service Plan. *Resident’s #1 & #7 had their current code status updated on the Resident Face Sheet (Personal/Social Data Sheet). *All resident records will be audited to determine code status. That information will be added/updated on the Resident Face Sheet, Service Plan, and other required locations within the medical record, if needed. *This will be monitored during scheduled Core Check audits completed by the Directing Family Group and the results reported for Divisional Review Person Responsible: NCC/ACC & Designee/Dir./Divisional Leadership Target Completion Date: 6/30/2022 & ongoing
22VAC40-73-1140-B
Based on record reviewed and staff interviewed, the facility failed to ensure within four months of starting employment in the safe, secure, environment, direct care staff shall attend at least 10 hours of training in cognitive impairment that meets the required of the 22VAC40-73-1140-C.
Evidence
  1. Staff #4 did not have documentation of 10 hours of cognitive training within 4 months of hire, staff’s record document 3 hours of dementia training (12-8-20). Staff’s date of hire was documented as 12-1-20.
  2. Staff #8’s record documented 9 hours 15 minutes of cognitive training within 4 months of hire. Staff’s date of hire was documented as 10-11-21.
Plan of correction
*Staff #4 & #8 training records were audited to assure that their current training requirements are up to date. *Requested training records to printed, by date range, starting on their hire/anniversary date thru the date prior to their anniversary date of the following year to assure that the correct training dates/content are reflected on their training record. *This will be monitored during monthly training record audits and reviewed weekly by the Directing Family Group and the results reported for Divisional Review. Person Responsible: Dir./Divisional Leadership Target Completion Date: 6/30/2022 & ongoing
22VAC40-73-210-F
Based on record reviewed and staff interviewed, the facility failed to ensure at least two of the required hours of training shall focus on infection control and prevention. When adults with mental impairments resident in the facility, at least four of the required hours shall focus on topics related to residents’ mental impairments.
Evidence
  1. Staff #1’s record did not include documentation of annual infection control and prevention training. Staff’s date of hire documented as 11-21-19.
  2. Staff #3’s record documented 1 hour of infection control and prevention (8-28-21), staff’s date of hire was dated as 10-7-19.
  3. Staff #4’s infection control document dated 12-1-21 did not document hours of training. Staff’s date of hire was dated 12-1-20.
Plan of correction
*The annual training outline was reviewed and updated to include additional training in the area of infection control. All newly hired staff will be required to complete this as a part of their initial new hire training and annually thereafter. *The 1 hour Infection Control training received along with the Annual Med Tech Refresher course will be scheduled within 1 year of when it was last offered at the Branch to assure that it is received within 12 months of when it was last scheduled. *This will be monitored during monthly training record audits and reviewed monthly by the Directing Family Group and the results reported for Divisional Review. Person Responsible: NCC/ACC/Divisional Leadership Target Completion Date; 6/16/22 & ongoing
22VAC40-73-440-H
Based on record reviewed and staff interviewed, the facility failed to ensure an annual reassessment, using the uniformed assessment instrument (UAI) shall be utilized to determine whether a resident’s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident.
Evidence
  1. On 4-7-22, resident #3’s resident did not include documentation of a uniformed assessment instrument (UAI). The record documented the resident’s date of admission was 3-5-21.
  2. On 4-7-22, resident #4’s record did not include documentation of a UAI. The record documented the resident’s date of admission was 2-25-21, the UAI in the record was dated 3-23-21 and signed by staff #1 and #10.
Plan of correction
*Resident’s #3 & #4 have the appropriate/current UAI in the Medical Record. *All current resident Medical Records will be audited to assure that each contains the appropriate/current UAI and that Bickford’s Chart Thinning Policy is being followed with regards to transferring documents to thinned records files maintained on site. *During future on-site inspections and monitoring visits, a member of the Directing Family Group will accompany the Licensing Inspector during the medical record review to assure that all documents are located within the medical record or retrieved from the location where they are maintained. *Those trained and designated to complete and update the UAI, as scheduled or indicated, have been instructed to obtain the Director’s signature and file the finalized document in the resident’s medical record immediately following completion. * This will be monitored during scheduled Core Check audits completed by the Directing Family Group and the results reported for Divisional Review Person Responsible: NCC/ACC or Designee/Dir./Divisional Leadership Target Completion Date: 6/30/2022 & ongoing
22VAC40-73-290-A
Based on document reviewed and staff interviewed, the facility failed to ensure the staff’s written schedule include all required information.
Evidence
  1. The April 2022 dietary schedule received on 4-12-22 documented only the first name or partial name of staff members. The schedule did not document staff’s job classification.
  2. The written work schedules provided did not include an indication of whomever is in charge at any given time.
Plan of correction
*The Kitchen Manager begun using an Excel Spreadsheet schedule template on 5/29/22 that will include the staff member’s full name and position being worked on each scheduled shift. *The monthly schedule will be reviewed monthly by the Director, prior to posting, to assure that all required information is included Person Responsible: KM/Dir/Divisional Leadership Target Completion Date:
22VAC40-73-440-A
Based on record review and staff interviewed, the facility failed to ensure prior to admission, the resident should be assessed face-to-face using the uniformed assessment instrument (UAI) in accordance with the Assessment in Assisted Living Facilities (22VAC30-110) for three of nine records reviewed.
Evidence
  1. On 4-7-22, resident #6’s record did not include a UAI. The resident’s record documented date of admission was 1-17-22.
  2. On 4-7-22, resident #8’s record did not include a UAI. The resident’s record documented date of admission was 4-5-22.
  3. On 4-7-22, resident #9’s record did not include a UAI. The resident’s record documented date of admission was 11-1-21.
Plan of correction
*Resident #6 UAI, signed and dated by staff members #1 & #10 on 1/12/22, is located in the medical record under the “Service Assessment” tab divider. *Resident #8 has been discharged. The closed records contain the UAI in question. *Resident #9 has been discharged. The closed records contain the UAI in question. *All current resident Medical Records will be audited to assure that each contains the appropriate/current UAI and that Bickford’s Chart Thinning Policy is being followed with regards to transferring documents to thinned records files maintained on site. * During future on-site inspections and monitoring visits, a member of the Directing Family Group will accompany the Licensing Inspector during the medical record review to assure that all documents are located within the medical record or retrieved from the location where they are maintained. *Those trained and designated to complete and update the UAI, as scheduled or indicated, have been instructed to obtain the Director’s signature and file the finalized document in the resident’s medical record immediately following completion. * This will be monitored during scheduled Core Check audits completed by the Directing Family Group and the results reported for Divisional Review Person Responsible: NCC/ACC or designee/Dir./Divisional Leadership Target Completion Date: 6/30/2022 & ongoing
22VAC40-73-100-C-2
Based on observation and staff interviewed, the facility failed to ensure it followed its infection control program.
Evidence
  1. On 4-7-22 during medication pass observation with staff #3, a check of resident #1’s glucose equipment was completed. The resident’s auto/needle injector on the medication cart was not labeled with the resident’s name.
  2. Staff #3 acknowledged the aforementioned resident’s glucose injector was not labeled.
Plan of correction
*Resident #1 had his lancet device properly labeled by the NCC. *All other residents receiving accu-checks had their lancet devices to ensure that they were properly labeled. *All RMAs will be educated on proper labeling of all medication related devices. Those items will be labeled at the time of receipt. * This will be monitored during the weekly medication audits. * The findings from those audits will be reviewed weekly by the Directing Family Group and the results reported for Divisional Review. Person Responsible: NCC/ACC/Divisional Leadership Target Completion Date: 6/16/22 & ongoing
22VAC40-73-470-A
Based on record reviewed and staff interviewed, the facility failed to ensure, either directly or indirectly, that the health care service needs of residents are met.
Evidence
  1. On 4-7-22, resident #1’s physical examination dated 1-21-22 documented Physical Therapy recommended. The resident’s record did not include documentation of physical therapy evaluation and/or services provided.
  2. On 4-7-22, resident #3’s physical examination dated 3-3-21 documented Physical therapy, Occupational therapy and Speech therapy evaluate and treat. The record did not include documentation of therapy services or an evaluation. The ISP dated 3-18-21 did not include documentation of therapy services.
  3. On 4-7-22, resident #4’s physical examination updated 2-25-21 documented Physical therapy recommended. The record also included a physician’s order signed and dated 3-11-21 for physical therapy, occupational therapy and speech therapy. The record did not include documentation of an evaluation or services provided. The individual service plan (ISP) dated 8-28-21 in the record did not document services received or achieved outcome date.
Plan of correction
*Resident’s #1, #3, & #4 Medical Records contain any current Physical, Occupational and Speech Therapy evaluations and notes as outlined in Bickford’s Chart Thinning Policy. *All current resident Medical Records will be audited to assure that they contain any current Physical, Occupational and Speech Therapy evaluations and notes and that Bickford’s Chart Thinning Policy is being followed with regards to transferring documents to thinned records files maintained on site. *During future on-site inspections and monitoring visits, a member of the Directing Family Group will accompany the Licensing Inspector during the medical record review to assure that all documents are located within the medical record or retrieved from the location where they are maintained. *This will be monitored during scheduled Core Check audits completed by the Directing Family Group and the results reported for Divisional Review Person Responsible: NCC/ACC or Designee/Dir./Divisional Leadership Target Completion Date: 6/30/2022 & ongoing
22VAC40-73-580-D
Based on record review and staff interviewed, the facility failed to ensure when the uniformed assessment instrument (UAI) assessed resident as dependent in eating/feeding, the individualized service plan (SIP) shall indicate an approximate amount of time needed for meals to ensure needs are met.
Evidence
  1. On 4-7-22, resident #7’s uniformed assessment instrument (UAI) dated 10-24-21 documented resident is fed by others. The individualized service plan (ISP) dated 10-24-21 did not document an approximate amount of time needed for meals to ensure resident’s needs are met.
Plan of correction
*Resident #7 has been discharged. *All other residents assessed as dependent in feeding on their UAI will have their Service Plans updated to include how much time is required by each to complete their meals to assure that their needs are being met. *This will be monitored during scheduled Core Check audits completed by the Directing Family Group and the results reported for Divisional Review Person Responsible: NCC/ACC or Designee/Dir./Divisional Leadership Target Completion Date: 6/30/2022 & ongoing
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition for three of nine records reviewed.
Evidence
  1. On 4-7-22, resident #2’s individualized service plan documented an end date (review) of 3-2022. The ISP in the record was signed and dated by the developer, administrator and resident on 9-23-21. The resident’s record documented the date of admission was 9-22-20.
  2. On 4-7-21, resident #3’s ISP dated 3-18-21 documented an end date (review) of 9-2021. The record included a preliminary dated 2-19-21 by facility staff and 3-6-21 by the legal representative. The record did not include a current ISP. The record documented the date of admission was 3-5-21.
  3. On 4-7-22, resident #4’s ISP dated 8-28-21 documented an end date (review) of 2-2022. The record did not include a current ISP. The resident’s record documented date of admission was 2-25-21.
Plan of correction
*Resident’s #2, #3, & #4 have the appropriate/current Service Plans in their Medical Records. *All current resident Medical Records will be audited to assure that each contains the appropriate/current Service Plans and that Bickford’s Chart Thinning Policy is being followed with regards to transferring documents to thinned records files maintained on site. *During future on-site inspections and monitoring visits, a member of the Directing Family Group will accompany the Licensing Inspector during the medical record review to assure that all documents are located within the medical record or retrieved from the location where they are maintained. *This will be monitored during scheduled Core Check audits completed by the Directing Family Group and the results reported for Divisional Review Person Responsible: NCC/ACC or Designee/Dir./Divisional Leadership Target Completion Date: 6/30/2022 & ongoing
22VAC40-73-440-K
Based on record reviewed and staff interviewed, the facility failed to ensure the uniformed assessment instrument (UAI) was in compliance with requirements set forth in 22VAC40-30-110.
Evidence
  1. On 4-7-22, resident #1’s uniformed assessment instrument (UAI) dated 2-6-22 (2-10-22) was completed and signed by facility representative # 9, but was not signed by the facility administrator or a designee.
Plan of correction
*Resident #1 UAI update/reassessment completed on 2/6/22 by staff #9 was reviewed and signed by the facility Administrator on 6/13/22. *All current resident Medical Records will be audited to assure that each contains UAIs that have been reviewed and signed by the Administrator or Designee. *Those trained and designated to complete and update the UAI, as scheduled or indicated, have been instructed to obtain the Director’s signature and file the finalized document in the resident’s medical record immediately following completion. * This will be monitored during scheduled Core Check audits completed by the Directing Family Group and the results reported for Divisional Review Person Responsible: NCC/ACC or Designee/Dir./Divisional Leadership Target Completion Date: 6/30/2022 & ongoing
22VAC40-73-410-A
Based on record reviewed and staff interviewed, the facility failed to ensure upon admission, the facility provided an orientation for new residents and their legal representative for three of nine records reviewed.
Evidence
  1. On 4-7-22 resident #1’s record documented the resident’s orientation to the facility was signed and dated by the representative on 2-10-22. The resident’s record documented the date of admission as 2-1-22.
  2. On 4-7-22 resident #4’s record did not include documentation of orientation. Resident’s date of admission in record was dated 2-25-21.
  3. On 4-7-22 resident #9’s record did not include documentation of orientation. Resident’s date of admission in record was dated 11-1-21.
Plan of correction
*Resident #1 completed a bed-hold agreement from 1/17/22 – 2/9/22. His physical move in date was 2/10/22, and the medical record was reviewed to assure that this date is accurately reflected. *Resident #1 copy of the Orientation Check List, signed at dated on 2/10/22, is located in the medical record behind the “Social” tab divider. The original is located in the Administrative Record. * Resident #4 copy of the Resident Orientation Checklist, signed and dated on 2/25/21, is located in the medical record behind the “Social” tab divider. The original is located in the Administrative Record. *Resident #9 copy of the Resident Orientation Checklist, signed and dated on 11/1/21, is located in the medical record behind the “Social” tab divider. The original is located in the Administrative Record. Person Responsible: NCC/ACC,Dir./CRD/Divisional Leadership Target Completion Date: 6/6/2022 & ongoing
22VAC40-73-1110-C
Based on record reviewed and staff interviewed, the facility failed to ensure whenever warranted by a change in a resident’s condition, the licensee, administrator, or designee shall also perform a review of the appropriateness of continued placement in the unit.
Evidence
  1. On 4-7-22, resident #1 was observed receiving service outside of the safe, secure unit. Staff #1 stated the resident was first placed on the unit when admitted to the facility. The resident was later determined to not need to be on the safe, secure unit. Resident was relocated to the assisted living (AL) unit. The facility Matix Care 2022, Resident Census document noted resident relocated to the AL unit of the facility on 3-29-22. The resident’s record did not include documentation of reassessment by the facility.
Plan of correction
*Resident #1 Medical Record currently contains all reassessment documentation required for a level of care change from the Special Care Unit to Assisted Living. *Those trained and designated to complete and update the UAI, Service Plans, and other reassessment documentation, as scheduled or indicated, have been instructed to obtain the Director’s signature and file the finalized document in the resident’s medical record immediately following completion. *During future on-site inspections and monitoring visits, a member of the Directing Family Group will accompany the Licensing Inspector during the medical record review to assure that all documents are located within the medical record or retrieved from the location where they are maintained. Person Responsible: NCC/ACC or Designee/Dir./Divisional Leadership Target Completion Date: 6/30/2022 & ongoing
22VAC40-73-250-D
Based on document reviewed and staff interviewed, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility shall submit the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as
Evidence
  1. s by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. Staff #6’s TB screening documentation was dated 11-30-21 by staff #10. Staff’s date of hire was dated 11-22-21. The document from a local treating clinic was dated 9-7-20.
Plan of correction
*All newly hired staff provide their most recent TB results at the time of hire or receive testing. Those providing test previous test results also receive a screening performed by the Nursing Coordinators. *The Branch will update their records to include written consent from the Doctor/Nurse Practitioner to perform routine TB screenings using the DSS or VDH approved form. *This authorization will be updated, as required, to include those currently authorized to complete this task. Person Responsible: NCC/ACC/Divisional Leadership Target Completion Date: 6/30/22 & ongoing
22VAC40-73-680-I
Based on document reviewed and staff interviewed, the facility failed to ensure the medication administration record (MAR) included all required information.
Evidence
  1. Resident #2’s April 2022 medication administration record (MAR) did not include a diagnosis, condition, or specific indications for Eliquis, Prevagen, and Robaxin.
  2. Staff #3 acknowledged the MAR did not include the diagnosis for the aforementioned resident’s medication on 4-7-22.
Plan of correction
*Resident #2 had their MAR updated to reflect the diagnosis, condition, or specific indications for Eliquis, Prevagen, and Robaxin. *The NCC/ACC will conduct a 100% audit of all MARs to assure that all resident medication orders also contain a diagnosis, condition, or specific indications. *All new medication orders will be reviewed by the NCC/ACC/LPN or RMA, prior to sending to the pharmacy, to assure that the orders also contain a diagnosis, condition, or specific indications *The NCC/ACC/LPN to conduct weekly medication audits, utilizing QuickMar, to assure that all ordered medications have a diagnosis, condition, or specific indications. * The findings from those audits will be reviewed weekly by the Directing Family Group and the results reported for Divisional Review.
February 7, 2022Complaint survey8 violations
Inspection dates
02/07/2022; 02/10/2022; 02/24/2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS
Comments
An unannounced joint complaint inspection was conducted on 2-7-22 (ar 09:30 a.m./dep 2:00 p.m.) regarding allegations received in the licensing office of resident care (pressure ulcers, bruised on lower legs, compression fracture and severely malnourished. Staff interviews and resident records were reviewed and the information gathered supports the allegation, therefore the complaint is "valid". An exit meeting was conducted on 2-7-22 and 2-24-22. The Acknowledgement Form was sent via email. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible. POC due 4-7-22.
Violations
22VAC40-73-310-H
Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals in the assisted living with any conditions or care need prohibited by the regulation and Code of Virginia.
Evidence
  1. Resident #1’s February 2022 medication administration record (MAR) documented resident prescribed Lorazepam and Haloperidol, prescriber’s order signed and dated 2-4-22.
  2. On 2-7-22 a request for the treatment plans for the psychotropic medications was requested but not received.
  3. On 2-7-22 during exit meeting, staff #1 and #2 acknowledged treatment plan for resident #1’s psychotropic medications was not available.
Plan of correction
Not published by VDSS.
22VAC40-73-560-E
Based on record reviewed and staff interviewed, the facility failed to ensure the information in the resident’s record was kept current.
Evidence
  1. Resident #1’s social data form documented resident preference in the event of cardiac or respiratory arrest was Do Not Resuscitate (DNR). The facility “Resident Emergency Code Status” dated by staff #1 on 2-24-21 noted the resident as “NO resuscitation should be attempted….”
  2. The resident’s individualized service plans (ISPs) dated 3-29-21 and 8-25-21 documented resident code status as “DNR”.
  3. On 2-4-22 the resident returned from a hospital stay with a DNR signed and dated 1-31-21. The resident’s record did not have a signed physician’s copy of a DNR order in the resident’s record until resident’s return from a local hospital on 2-3-22.
  4. Staff #1 and #2 acknowledged the resident’s record did not reflect the resident’s correct code status during stay from 2-21-21 to 2-3-22.
Plan of correction
Not published by VDSS.
22VAC40-73-580-F
Based on record reviewed and staff interviewed, the facility failed to ensure it implemented interventions as soon as a nutritional problem was suspected.
Evidence
  1. Progress note dated 2-26-21 documented resident was admitted to the facility weighing 108 pounds.
  2. On 2-7-22, staff #1 provided the “Resident’s Vital Signs” form which documented resident #1’s weight from 4-1-21 through 1-27-22. This weight chart noted resident’s gradual weight loss as follows: (a) 4-1-21 (100 pounds (lbs); (b) 5-1-21 (98 lbs); (c)5-24- 21 (92 lbs); (d) 6-1-21 (90 lbs); (e) 6-10-21 (91 lbs); (f) 7-1-21 (90 lbs); (g) 8-1-21 (90 lbs); (h) 9-1-21 (90 lbs); (i) 10-1-21 (83.2 lbs); (i) 11-1-21 (86 lbs); (j) 12-1-21 (112); (k) 1-1-22 (81.4 lbs); (l) 1-25-22 (72.3 lbs) and (m) 1-27-22 (72.3 lbs). Resident #1’s weight loss from admission 2-26-21 to 1-24-22 totaled 35.7 pounds.
  3. The facilities dietician report dated 7-29-21 recommended facility “provide lots of sauces, gravies, butter, etc.” The dietician report dated 10-19-21 documented resident, “has lost 7# in past 90 days…recommend provide resident with whole white or chocolate milk. Would resident enjoy the fortified cereal?’”. Review of resident’s record on 2-7-22 with facility staff did not have documentation of these recommendations.
  4. Resident’s physician progress noted signed and dated 5-13-21, documented, “Depressed mood…resident with flat affect and withdrawn possibly due to having to adjust to moving here (ALF). Continue to monitor resident weight, po intake nourishment as part of the eval for depression”.
  5. Facility policy, “PP - 40600 - Nutrition Intervention Protocol” page 1 noted, “Residents identified as high risk may be placed on the Nutrition Intervention Protocol. High risk residents may include residents who are below Ideal Body Weight (IBW), have experienced recent weight loss, have skin breakdown, have low albumin levels, have poor food intake, etc. Special care should be taken to address those residents who have had a 5% loss in 1 month, a 7.5% gain or loss in three months or 10% gain or loss in 6 months. On 2-7-22, there was no documentation in resident’s record of nutritional intervention.
  6. On 2-7-22 staff #1 and #2 acknowledged no intervention was in place for resident #1.
Plan of correction
Not published by VDSS.
22VAC40-73-70-A
Based on record review and staff interviewed, the facility failed to ensure it reported to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety or welfare of any resident.
Evidence
  1. On 2-7-22, during complaint inspection, the inspector was provided a copy of an incident report for resident #1 for an incident that occurred on 1-27-22. Report documented admitted to hospital with pneumonia, small fractures in the lumbar and thoracic regions of the spine and sternum. Determination of how old fractures were undetermined; resident had diagnosis consistent with pathological fractures.
  2. Resident’s progress note dated 1-17-22 documented resident was sent to hospital on 1-14-22 “for possible choking/? aspiration”.
  3. Resident #1’s progress notes dated 2-26-21 documented, by staff #2, noted resident had a “stage 2 on coccyx measuring 0.5 cm X 0.2 cm”. Resident’s progress note dated 3-4-21 also documented resident was “admitted with stage II coccyx and left heal had DTI”. This was not reported to the licensing office.
  4. Facility incident reporting policy noted the following for reporting of incidents, “PP-11150-Reportable Events (VA) -2), noted “State-specific Reporting Requirement (a) The Branch will report to the regional licensing office within 24 hours any major incident that has negatively affected or threatens the life, health, safety or welfare of any Resident”.
  5. On 2-7-22 and 2-24-22 during exit meeting, staff #1 acknowledged incident reports were not sent to licensing office.
Plan of correction
Not published by VDSS.
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs.
Evidence
  1. Resident #1’s uniformed assessment instrument (UAI) dated 2-2-22 noted dressing need assessed as mechanical help/ physical assistance. The individualized service plan (ISP) dated 2-2-22 did not document type of mechanical help needed. Resident’s eating/feeding assessed as Supervision. The ISP documented physical/supervision, staff to setup her meal and encouragement to eat and drink at each meal. Resident prescribed a mechanical soft diet which is mechanical need. The ISP also noted resident is to be fed by staff if she is too weak to feed herself, the UAI did not assess resident as dependent with feeding/eating.
  2. Resident prescribed Oxygen 2/L via nasal cannula- continuous- concentrator; prescriber signed 2-3-22 also on February 2022 medication administration record. Oxygen information also documented in resident’s Hospice Skilled Nursing Visit Noted dated 2-3-22 and electronically signed on 2-5-22. The resident’s need for Oxygen not documented on ISP dated 2-2-22.
  3. On 2-7-22 during exit, staff #1 and #2 acknowledged ISP did not include all assessed needs.
Plan of correction
Not published by VDSS.
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was updated as needed for a significant change of a resident’s condition.
Evidence
  1. Resident’s record included Speech Therapy (ST) 4-26-21 for speech deficit based on hearing loss and signed by prescriber on 7-13-21. ST Re-Evaluation document for services 6-30-21 through 8-26-21, Safe Swallowing Evaluation conducted on 6-30-21; oropharyngeal dysphagia diagnosis, ST 1 X week for 4 weeks effective 7-4-21. Speech Therapy services not documented on ISP dated 3-19-21 and not on ISP dated 8-25-21.
  2. Record also included a physician’s order dated 3-16-21 for “SN HH PT/OT/ST for choking episode.
  3. On 2-7-22 during exit, staff #1 and #2 acknowledgement ISP did not include all assessed needs.
Plan of correction
Not published by VDSS.
22VAC40-73-680-E
Based on record reviewed and staff interviewed, the facility failed to ensure a medical procedure or treatment ordered by a physician or other prescriber was provided according to his instructions and documented. The documentation shall be maintained in the resident record.
Evidence
  1. Resident #1’s record contained a physician’s order signed and dated 5-13-21 requesting the facility, “Check weight every two weeks X one month. Monitor food/ po intake of each meal X one week”.
  2. Staff # 1 was asked about the resident’s food intake and the facility’s documentation of resident’s food consumption. Staff #1 stated the “we do not document how much the resident eats, we don’t check to see how much they eat. We just give them their trays”.
  3. Staff #1 and #2 was asked about the physician’s order in the resident’s chart requesting facility document resident’s consumption.
  4. On 2-7-22 staff #1 and #2 acknowledged not being aware of such an order.
Plan of correction
Not published by VDSS.
22VAC40-73-470-C
Based on record reviewed and staff interviewed, the facility failed to provide services to prevent clinically avoidable complications such as malnutrition.
Evidence
  1. Resident #1’s was admitted to a local hospital on 1-27-22 and returned to the facility on 2-3-22. The hospital’s transfer summary noted on 1-28-22, “severe protein-calorie malnutrition (Gomez: less than 60% of standard weight) HCC; frail elderly; and debility. Also noted on 1-27-22, “pressure injury sacrum, pressure injury; spine medial”. Wound care provided and dressing changes provided during hospital stay. On 2-1-22, resident’s weigh 37.7 kg (83 lb 1.8 oz). Resident returned to facility with hospice services.
  2. Hospice note dated 2-5-22, “resident has exhibited decline by decrease appetite, decreased functional status and significant weight loss since admission to facility….current weight is 83.61 lbs per recent hospital paperwork. In 04/2021 weight was 100 lbs >August: 90 lbs. Albumin is 1.9”.
  3. On 2-24-22, during exit meeting, regulation regarding clinically avoidable complications per the regulation discussed with staff #1 and #3.
Plan of correction
Not published by VDSS.
July 22, 2021Inspection5 violations
Inspection dates
7/22/2021;10/1/2021;10/27/2021
Areas reviewed
22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS
Comments
A non-mandated monitoring inspection was initiated on 7-22-21 and concluded on 11-1-21. The Registered Nurse Coordinator was contacted by telephone to conduct the inspection. The licensing inspector emailed the Registered Nurse Coordinator a list of documentation required to complete the inspection. The licensing inspector conducted a joint on-site observation at the facility on 10-1-21. The evidence gathered during the inspection support non-compliance with standards or law, and violations were issued.
Violations
22VAC40-73-680-I
Based on document reviewed and staff interviewed, the facility failed to ensure the medication administration record (MAR) included all required information.
Evidence
  1. Resident #2’s May 2021 medication administration record (MAR) documented Fluconazole, however, the MAR did not include a diagnosis, condition, or specific indications for administering the drug. Resident’s July MAR documented Zamzaric, however, the MAR did not include a diagnosis for the drug.
  2. Resident #3’s July 2021 MAR documented resident to wear Ted Hose, “on in the morning off at bedtime”, however, the MAR did not include a diagnosis, condition, or specific indications for the use of the Ted hose.
  3. On 10-27-21, discussion was conducted regarding the MARs missing the diagnosis for resident #2 and #3.
  4. On 11-1-21, staff #1 acknowledged resident #2’s MAR did not include diagnosis for the aforementioned medications and resident #3’s MAR did not include diagnosis for the use of Ted Hose.
Plan of correction
*Residents #2 and #3 had the missing diagnosis added to their MARs. *A 100% audit was conducted by the RNC to assure that all resident medications had an appropriate diagnosis listed on the MAR. *All medications on the MARs that are missing a diagnosis will have the appropriate diagnosis hand-written on a printed MAR by the RNC or ACC, next to that medication, that will then be faxed to the Pharmacy to be profiled on the MAR. *That faxed copy will be retained and used during the Weekly Med Audits to assure that the proper diagnosis was added by the Pharmacy. *The findings from those audits will be reviewed weekly and the DFGs and the results reported for Divisional Review. Responsible Party: RNC/ACC/Director/Divisional Director Target Date: 11/19/2021 & ongoing
22VAC40-73-870-A
Based on observation and staff interviewed, the facility failed to ensure the interior of the building was maintained in good repair and kept clean and free of rubbish.
Evidence
  1. On 10-1-21 during a tour of the facility with staff #1, the carpet in front of the nursing station on the assisted living unit was observed with a dark stain area approximately 7 x 5 inch. The carpet in the hallway in front of room #216 was also observed to have several dime sized spots and an approximate 1 in wide x 18 in long stain in the carpet.
  2. Staff #1 acknowledged the carpet stains during the tour on 10-1-21.
Plan of correction
*It is always the expectation of this Branch to respond to any spills/staining on the carpet as timely as possible once identified. *Staff #1 had the carpet in front of the AL Nurses Station and in front of apartment #216 cleaned immediately upon the Inspector’s exit and emailed photos to the Inspector that evening showing that the areas in question were cleaned and that there were no stains remaining. *Staff #1 purchased a portable carpet cleaner, with instructions, to be used by our BFMs (staff) to address soiled areas on the carpet. If additional cleaning is required, it will be noted on the Maintenance Log to be addressed by Housekeeping. *Directing Family Group (Management Team) to observe the carpet during routine rounds for soiled areas and note any areas needing to be cleaned in the Maintenance Log. Responsible Party: RNC/ACC/Director Target Date: 10/1/2021 & ongoing
22VAC40-73-680-D
Based on document review and staff interview, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident #2’s May 2021 medication administration record (MAR) documented Nystatin powder, “apply topically four times a day for 7 days”. The mar was documented by staff on 5-10- through 5-15-21. A review of the nurse’s notes dated 5-8-21 at 20:00 p.m. documented, the new order was called to a local pharmacy. Nurse’s notes dated 5-9-21 at 10:00 a.m. documented, “medications p/u from pharmacy. Faxed written orders call to facility assigned pharmacy last night and delivered to the Branch. 1 st dose given upon arrival to the Branch after checking in”. However, the MAR did not document dosages for 8:00 a.m.; 12:00 p.m.; 4:00 p.m.; and 8:00 p.m. on 5- 8-21 neither on 5-9-21. The MAR documented the first dosage on 5-10-21 at 8:00 a.m.
  2. Resident #2’s Nystatin documentation on May 2021’s MAR reviewed with staff #1 and staff #2 on 10-27-21.
Plan of correction
*Resident #2’s Provider was notified about the number of documented doses of Nystatin powder that was administered. There were no new orders. *All prescription orders intended to treat a short-term acute condition will be faxed to the pharmacy to be filled, as ordered. Once the medication is received, the Branch will notify the pharmacy that it was received and inform them of when the 1st dose will be administered so that the start and stop dates can be profiled to assure that the date range allows for all ordered doses to be administered. *The RNC and ACC to conduct a 24hr. audit after the receipt of all short-term acute condition medication orders to assure that the medication arrived, that administration has begun, has been documented, and has been charted. They will also review the start and stop dates to assure that the date range allows for all ordered doses to be administered as prescribed. *The findings from those audits will be monitored weekly and the results reported for Divisional Review. Person responsible: RNC/ACC/Divisional Director Target completion date: 11/5/2021 & ongoing
22VAC40-73-310-H
Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals in the assisted living with any conditions or care need prohibited by the regulation and Code of Virginia.
Evidence
  1. Resident #1’s July 2021 medication administration record (MAR) documented resident prescribed Buspirone; prescriber’s order signed and dated 7-8-21.
  2. Resident #3’s July 2021 MAR documented resident prescribed Seroquel; prescriber’s order signed and dated 7-18-21.
  3. On 10-27-21 a request for the treatment plan for the psychotropic medications were requested but not received.
  4. On 11-1-21, staff #1 acknowledged treatment plan for resident #1’s Buspirone and resident #3’s Seroquel was not provided for review.
Plan of correction
*Resident #1 & resident #3 did receive a Psychoactive Medication Treatment Plan for their medications referenced. *A 100% audit was conducted of all resident medication profiles to assure that any medication requiring a Psychoactive Medication Treatment Plan was obtained from their provider and filed in their record. *As a part of the Weekly Med Audits, a Psychoactive Medication Report will be printed and used for audit purposes to assure that all Psychoactive Medication Orders have an appropriate Treatment Plan. *The findings from those audits will be monitored weekly and the results reported for Divisional Review. Responsible Party: RNC/ACC/Divisional Director Target Date: 11/5/2021 & ongoing
22VAC40-73-930-A
Based on observation and staff interview, the facility failed to ensure when the call bell/signaling device is pulled, direct care staff is alert of the need for assistance.
Evidence
  1. On 10-1-21 during rounds on the facility’s safe, secure unit, the call bell was pulled in room #502 at 9:47 a.m. At 9: 57 a.m., there was no staff response. Staff #2 and the inspectors were informed that staff #5 was assigned. However, it was later learned that staff #5 did not have a pager and therefore could not respond to the call bell for room #502.
  2. Staff #2 acknowledged staff could not respond to the call bell because staff #5 did not have a pager.
Plan of correction
*Staff #1 assured that all pagers were in proper working order, labeled, and available so that each BFM (staff member) assigned to Resident Care had a pager to use to respond to call bells. *Staff #2 reviewed the pager/call bell policy immediately with those on duty at the time of the Inspection on 10/1/21. This was also reviewed with all BFMs, who provide Resident Care, at a Mandatory Nursing Meeting/In-service held on 10/27/21 *The BFM Designated In Charge on each shift is responsible for overseeing that the pagers are being worn and used to respond to resident call bells. *The Directing Family Group (Management Team) will conduct announced call bell audits to monitor for timely response and will also observe to assure that all BFMs responsible for Resident Care are wearing the pagers, per policy. *The findings from those audits will be reviewed weekly by the DFGs and the results reported for Divisional Review. Responsible Party: RNC/ACC & Designee/Director/Divisional Director Target Date: 10/27/2021 & ongoing
May 3, 2021Inspection4 violations
Inspection dates
May 3, 2021 , May 4, 2021 , May 5, 2021 and May 6, 2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 05-03-2021 and concluded on 05-06-2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 60. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, criminal background checks and sworn disclosures of newly hired staff, staff schedules, fire drills, fire and health inspection reports, dietary oversight, and healthcare oversight. Information gathered during the inspection determined non-compliance's with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-450-F
Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) was reviewed and updated as needed as the condition of the resident changes.
Evidence
  1. Resident #4’s signed physician’s orders dated 02-23-2021 documented, oxygen- 2L via NC [nasal cannula] PRN [as needed]. The current ISP dated 06-15-2020 was not updated to reflect the new need for oxygen.
  2. Resident #2’s “Report of Resident Physical Examination” dated 07-24-2020 documented a no added salt diet. The resident’s signed physician’s order dated 03-22-2021 documented ?Mechanical soft diet w/chopped meats. Thickened liquids (Nectar thick)?; however, the current ISP dated 02-11-2021 was not updated to reflect the resident’s current diet.
  3. Resident #3’s “Home Health Certification Plan of Care” form documented a start of care for skilled nursing on 03-18- 2021 for an open wound. Home Health notes dated 05-04-2021 documented the resident continues to receive nursing services for wound care. The current ISP dated 01-26-2021 was not updated to reflect the need for skilled nursing services for wound care.
  4. Staff #1 and staff #2 acknowledged the residents ISP’s were not updated to reflect the residents aforementioned needs.
Plan of correction
*Resident #4, #2, and #3 had their ISP’s updated to reflect the most current orders provided by their Providers. *All new orders are to be faxed to ValuMed Pharmacy as soon as feasibly possible after receipt to assure that the order was profiled correctly, activated in QuickMar, and appropriate items delivered, if indicated. * A copy of all new orders will be placed in a designated “New Orders” binder to be referenced by the RNC and ACC while updating the ISP. The RNC and ACC will profile and then initial those items appropriate for inclusion on the ISP. *The RNC and ACC, together, will cross audit the ISP against the Physician Order Sheet and UAI, when routine updates occur, to assure that all required items are profiled on the ISP. *The ISP will be reviewed and signed by the RNC or ACC the Director the designated Resident Representative and the *The ISP will be reviewed, and signed, by the RNC or ACC, the Director, the designated Resident Representative, and the Resident (when appropriate).
22VAC40-73-650-B
Based on record review and interview, the facility failed to ensure prescriber’s orders for administration of all prescription and over-the-counter medications, identified the diagnosis or specific indications for administering each drug.
Evidence
  1. Resident #1’s signed prescriber’s orders did not include a diagnosis or specific indications for Sodium Bicar 650mg (order dated 04-01-2021); Seroquel 25mg and Lexapro 10mg (order dated 04-15-2021); and Norvasc 5g (order dated 04- 15-2021).
  2. Staff #1 and staff #2 acknowledged resident #1 prescriber’s orders did not include the diagnosis or specific indications for administering the aforementioned medications.
Plan of correction
*The resident’s Provider was called to confirm the appropriate diagnosis and indications for use for those medications referenced. *Resident #1 MAR was updated to include an appropriate diagnosis for all medications ordered. *All resident MARs will be audited to assure that all medications ordered have a corresponding diagnosis and indication for use, if indicated. * The RNC and ACC are to conduct weekly Med Audits, as outlined by Branch Support, to identify any discrepancies with the medication administration process so that there can be quick intervention.
22VAC40-73-680-D
Based on record review and interview, the facility did not administer medications in accordance with the physician's instructions.
Evidence
  1. Resident #2’s signed oral physician’s order dated 04-02-2021 documented, ?Decrease afternoon dose of Seroquel to 25mg for agitation??
  2. Resident #2’s April 2021 Medication Administration Record documented staff administered 1 tab of Seroquel 50mg at 1:00 PM on 04-03-2021 through 04-05-2021.
  3. Prescriber #1 (NP) acknowledged resident #2 was not administered the correct dose of Seroquel for 3 days.
Plan of correction
*The Provider was notified that resident #2 dose reduction, ordered on April 2, 2021, did not start until April 6, 2021. *All new orders are to be faxed to ValuMed Pharmacy as soon as feasibly possible after receipt. Any delays in that process are to be reported to the Provider as soon as the delay is discovered for notification purposes and to inquire if any additional orders are required. *A copy of all new orders will be placed in a designated “New Orders” binder, that will be checked daily for 1st and 2nd checks, to assure that the order was profiled correctly, activated in QuickMar, and delivered if indicated. *The RNC and ACC are to conduct weekly Med Audits, as outlined by Branch Support, to identify any discrepancies with the medication administration process so that there can be quick intervention. *The findings from those audits will be monitored weekly and the results reported for Divisional Review.
22VAC40-73-970-E
Based on record review and interview, the fire and emergency evacuation drills record did not identify the person conducting the drill nor method used for notification of the drill.
Evidence
  1. Fire and emergency evacuation drill conducted on 04-28-2021 did not include the person’s name conducting the drill.
  2. Fire and emergency evacuation drill conducted on 02-28-2021 did not include the method used for notification of the drill.
  3. Staff #1 did not provide additional documentation of the aforementioned requirements and acknowledged the aforementioned information was not recorded on the fire and emergency evacuation drills.
Plan of correction
*The forms used to document the Fire Drills conducted on 2/28/2021 and 4/28/2021 had the missing information added to those forms, and those forms were provided to the Licensing Inspector on 5/6/2021 *Moving forward, all Fire Drill forms will be reviewed and countersigned by one of Bickfords? Directing Family Members to assure that all required areas on the form are completed, as required, and that the form contains no blank areas.
April 5, 2021Inspection7 violations
Inspection dates
April 5, 2021 , April 7, 2021 , April 9, 2021 , April 13, 2021 and April 14, 2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-80 SANCTIONS
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 04-05-2021 and concluded on 04-14-2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 61. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records and staff schedules. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-70-A
Based on record review and interview, the facility failed to report to the regional licensing office within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. The regional licensing office did not receive incident reports from the facility within 24 hours regarding the following incidents: A. Staff “Communication Log” dated 03-20-2021 documented, ?room #305 [confirmed by staff #1 as resident #1] was found on the floor“.” Resident returned with a diagnosis of a facial laceration per the “After Visit Summary” dated 03-20-
  2. B. Resident #3’s “Progress Notes” dated 03-17-2021 documented, ?Resident was leaning forward in [resident] w/c [wheelchair]“ BFM’s [Bickford Family Member] noticed resident on the floor” Resident c/o pain in right leg which was slightly swollen?“ The resident’s ”Unusual Occurrence Nursing Evaluation“ form dated 03-18-2021 documented, ”x-ray revealed acute fracture.? C. Staff “Communication Log” dated 03-04-2021 documented, ?room #311 [confirmed by staff #1 as resident #5] fell in bathroom at 10:57 PM“.” Resident returned to the facility with a diagnosis of a scalp laceration and received staples per the “After Visit Summary” dated 03-05-2021.
  3. The regional licensing office did not receive an incident report from the facility regarding the following incident: A. Staff “Communication Log” dated 03-04-2021 documented, “room #316 [confirmed by staff #1 as resident #6] ”upon shift arrival resident was observed on floor“ Resident has laceration to left side of eye” applied steri strips to eye.?
  4. Staff #1 and staff #2 acknowledged the aforementioned incidents were not reported to the regional licensing office within the required timeframes.
Plan of correction
*A self-initiated audit from January 1, 2021 ? March 31, 2021 was conducted, prior to the start of this inspection, and any Resident or Branch incident/accident that should have been reported, as required, was submitted to our Licensing Inspector on March 31, 2021. *Resident #6, identified during the inspection as having an event that should have been reported, did have that event reported to DSS as required. *Those designated to be in charge in the absence of the Administrator will review and acknowledge the requirement to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens report to the regional licensing office, within 24 hours, any major incident that has negatively affected or that threatens the life, health, safety or welfare of any resident. *The Nurse on Call will be responsible for discussing the incident with the Director and then making the initial report to DSS. The Director and Divisional Director will be copied on that email notification. *The Director, or her designee, will be responsible for submitting the final report within 7 days of the event. The Divisional Director will be copied on that email notification.
22VAC40-73-640-A
Based on record review and interview, the facility failed to implement its medication management plan labeled ?PP- 61050-Medication Management (VA)?.
Evidence
  1. The facility’s medication management plan indicates staff will communicate any issues or observations related to medication administration and will communicate issues and observations to the prescribing physician.
  2. Resident #2’s March 2021 Medication Administration Record documented “resident refused” Siltussin Syp 100/5ML on 03-11-2021 through 03-24-2021.
  3. Staff #1 and staff #2 could not provide documentation that the physician was notified of the resident’s refusal on the aforementioned dates.
  4. Staff #1 and staff #2 acknowledged the facility did not implement its medication management plan.
Plan of correction
Disputed
22VAC40-73-650-A
Based on record review and interview, the facility failed to ensure no medications are started or discontinued by the facility without a valid order from a physician or other prescriber.
Evidence
  1. Resident #3’s hospital “ED Provider Notes” (signed and dated by the physician on 03-08-2021) documented Cephalexin (Keflex) 500mg- take 1 cap by mouth every 12 hours for 10 days for a diagnosis of Urinary Tract Infection with hematuria.
  2. Resident #3’s “Medical Practitioner’s Orders” documented: A. Order signed and dated 03-12-2021 from a Registered Nurse (RN) documented, “discontinue Keflex”. The order was not signed by a physician or other prescriber until 04-06-2021. B. Order signed and dated 03-29-2021 from an RN documented, ?Miconazole Nitrate powder 2%- apply small amount to buttocks 3x a day and PRN [as needed] for incontinence episodes- mix with Calmoseptine.? The order was not signed by a physician or other prescriber until 04-06-2021. C. The aforementioned orders were not labeled as an oral order.
  3. Resident #3’s March 2021 and April 2021 Medication Administration Record documented: A. Cephalexin 500mg administered at 8:00 AM and 8:00 PM on 03-09-2021 through 03-11-2021, and 03-12-2021 at 8:00 AM. The staff discontinued the Cephalexin 500mg on 03-12-2021 at 1:00 PM without a physician’s order. B. Staff administered Miconazole powder 2% on 03-30-2021 through 04-06-2021.
  4. Staff #1 and staff #2 acknowledged the facility started and discontinued resident #3’s aforementioned medications without a valid order from a physician or other prescriber.
Plan of correction
Disputed
22VAC40-73-680-C
Based on record review and interview, the facility failed to ensure medications are administered no earlier than one hour before and no later than one hour after the scheduled administration time.
Evidence
  1. March 2021 Medication Administration Records documented the following: A. Resident #1’s Arthr Pain Gel 1% and Medihoney was scheduled to be administered at 7:00 AM, and Docusate 100mg and Prednisone 20mg was scheduled at 8:00 AM; however, the “Med Pass Details” report documented the 7:00 AM and 8:00 AM aforementioned medications were administered at 10:14 AM on 03-08-2021. B. Resident #2’s Calcium Citrate 200-250, Asmanex 220mcg, Clopidogrel 75mg, Furosemide 20mg, Metoprolol 50mg, Multi-Vitamin, and Peg 3350 was scheduled to be administered at 8:00 AM; however, the “Med Pass Details” report documented the 8:00 AM aforementioned medications were administered at 11:01 AM on 03-02-2021, and at 9:40 AM on 03-08-2021 and 03-11-2021.
  2. Staff #1 and staff #2 acknowledged resident #1 and resident #2’s aforementioned medications were not administered no earlier than one hour before and no later than one hour after the scheduled administration time.
Plan of correction
* The Providers for residents #1 and #3 were notified that the medications were administered late and out of the ?hour before and hour after? administration timeframe. There were no new orders. *In an attempt to better balance the med pass between the 2 carts used for medication administration, the total resident med pass was equally divided between the AL cart to the MB cart so that the med pass can be completed within the 2- hour window for administration. * The RNC and ACC are to conduct weekly Med Audits, as outlined by Branch Support, to identify any discrepancies with the medication administration process so that there can be quick intervention. *The findings from those audits will be monitored weekly and the results reported for Divisional Review.
22VAC40-73-680-D
Based on record review and interview, the facility failed to ensure medications are administered in accordance with the physician's instructions.
Evidence
  1. Resident #1’s signed verbal physician’s order dated 03-15-2021 documented, ?Diflucan 150mg [Fluconazole] 1 dose on day 3, 5, and 7 of ABT [antibiotic therapy] for UTI.?
  2. Resident #1’s March 2021 Medication Administration Record (MAR) documented: A ?Fl l T b 150 3 5 7 (3/18 3/20 3/22 t 8 00 PM) A. ?Fluconazole Tab 150mg- Take one tablet by mouth once daily on days 3, 5, 7 (3/18, 3/20, 3/22 at 8:00 PM) of antibiotic for UTI.? B. The MAR did not document staff administered Fluconazole 150mg on 03-22-2021. C. Staff #1 and staff #2 could not provide documentation that the Fluconazole 150mg was administered to the resident on 03-22-2021.
  3. Resident #4’s signed physician’s order dated 03-10-2021 documented, ?Cephalexin (Keflex) 500mg PO [by mouth] Caps- Take 1 cap by mouth twice daily for 7 days. Start date: Mar 10, 2021, end date Mar 17, 2021.? Additionally, an order dated 03-02-2021 documented, “Avelox 400g- 1 tab PO QD [daily] x5 days for PNA.”
  4. Resident #4’s March 2021 MAR documented: A. Cephalexin 500mg administered on 03-12-2021 at 5:00 PM, 03-13-2021 through 03-16-2021 at 8:00 AM and 5:00 PM, and 03-17-2021 at 8:00 AM. The resident received Cephalexin 5 out of 7 days. B. 03-17-2021 at 6:36 PM, staff “Pass Notes” documented, Cephalexin 500mg was not administered because ?Last dose was already given. Completed.? C. Moxifloxacin 400mg [Avelox] administered on 03-05-2021 through 03-08-2021. The resident received Avelox 4 out of 5 days. D. Staff #1 and staff #2 could not provide documentation that the Cephalexin 500mg was administered to the resident on the 6th and 7th day, nor Avelox 400mg on the 5th day.
  5. Staff #1 and staff #2 acknowledged the aforementioned medications for resident #1 and resident #4 were not administered in accordance with the physician’s instructions.
Plan of correction
*The Providers for residents #1 and #3 were notified of the missed doses for the prescribed medications. There were no new orders. *The Providers for residents #1 and #3 were notified of the missed doses for the prescribed medications. There were no new orders. *The Branch is to notify ValuMed Pharmacy of all necessary changes/corrections to administration start/stop dates and times so that those updates can be made in the QuickMar electronic administration record. *ValuMed has secured a professional courier service to deliver all medications, filled by the after-hours local pharmacy, to the Branch in a timely manner. Those medications will be inventoried onto the Backup Pharmacy Medication Receiving Log. The RNC/ACC will verify that those medications have been profiled for administration. *The RNC and ACC are to review the ValuMed Manual as a refresher on all protocols regarding the pharmacy services, processes and procedures. *The RNC and ACC are to conduct weekly Med Audits, as outlined by Branch Support, to identify any discrepancies with the medication administration process so that there can be quick intervention. *The findings from those audits will be monitored weekly and the results reported for Divisional Review.
22VAC40-73-930-B
Based on record review and interview, the facility failed to make and document rounds no less than every two hours for each resident with an inability to use the signaling devices, once the resident has gone to bed each evening until the resident has arisen each morning, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility.
Evidence
  1. Resident #3’s most current Individualized Service Plan (ISP) dated 04-01-2021 documented, ?1 hour checks (with an identified date of 04-30-2020) - Staff will check on resident every 1 hours and as needed to ensure [resident] has not fallen or needs assistance.?
  2. The “Resident Apartment Nighttime Safety Checks Daily Log (VA)” for resident #3 did not include documentation of staff initials verifying 2 hour rounds were completed every two hours on 03-03-2021 and 03-04-2021 from 11:00 PM through 7:00 AM; and 03-12-2021 and 03-26-2021 from 6:00 PM through 10:00 PM.
  3. Resident #5’s most current ISP dated 02-24-2021 documented, ?2 hour checks (initiated on 10-06-2021) - resident will receive safety checks every two hours at night and during the day to ensure resident is safe and does not require assistance.?
  4. The “Resident Apartment Nighttime Safety Checks Daily Log (VA)” for resident #5 did not include documentation of staff initials verifying 2 hour rounds were completed every two hours on 03-01-2021 and 03-19-2021 at 11:00 PM, 1:00 AM, 3:00 AM, 5:00 AM, and 7:00 AM; 03-02-2021 and 03-25-2021 at 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM, and 7:00 AM; 03-03-2021 and 03-04-2021 from 11:00 PM through 7:00 AM; and 03-12-2021 and 03-26-2021 from 6:00 PM through 10:00 PM.
  5. Staff #1 and staff #2 could not provide additional documentation indicating one hour rounds (for resident #3) and two hour rounds (for resident #5) had been conducted as indicated on the ISP’s.
  6. Staff #1 and staff #2 acknowledged staff did not make rounds every hour or every two hours as required.
Plan of correction
*Residents #3 and #5 were discharged and no longer reside at our Branch. *One (1) hour safety checks will no longer be profiled on the service plan with the exception, if indicated, that the resident has a 1:1 safety companion in place. *All nursing BFMs will be required to review and sign/acknowledge the requirement for two (2) hour Night Time Safety Checks for those on Mary B’s and those in AL who meet the criteria for that safety measure. *The Night Time Safety Checks log will be reviewed each morning, for the previous day, to assure that they were documented completely by the BFM responsible for that task. *Weekly audits will be conducted, for the previous week, to assure that the documentation is complete, as required.
22VAC40-80-340-7-f
Based on record review and interview, the facility failed to adhere to the special order as provided in ? 63.2-1709.2 of the Code of Virginia and failed to contact guardians or other responsible persons of the adults currently in care in writing regarding the health and safety violations within 30 days of receipt of the special order.
Evidence
  1. Special Order was mailed to the licensee on 12-15-2020 via certified mail documented: a. The licensee is required to contact guardians or other responsible persons of the adults currently in care, as authorized by ? 63.2-1709.2 (B)(6) of the Code of Virginia; b. Within 30 days of receipt of the department's Special Order, the licensee shall contact in writing the guardians or other responsible persons; c. Information provided in the contact shall include (i) the Notice of lntent, the Violation Notice upon which the Notice of lntent was based and the Special Order; (ii) the date the contact was provided; and (iii) the name of the facility contact person, their title, and contact information that the guardians or other responsible persons can contact regarding comments or questions; d. The licensee shall supply evidence to the assigned licensing inspector that contacts have been made within 15 days of completion.
  2. On 01-11-2021, staff #1 was asked if the facility received the special order. Staff #1 stated the special order was mailed at the end of December.
  3. On 03-30-2021, staff #1 was asked if the facility notified the guardians or other responsible persons of the special order. Staff #1 provided an email dated 03-09-2021 documenting one resident’s responsible person was notified, however; the notification only addressed 1 out of 6 areas of noncompliance documented in the Notice of Intent.
  4. Staff #1 acknowledged the facility did not contact guardians or other responsible persons within 30 days of receipt of the Special Order and did not notify the assigned licensing inspector that contacts were made within 15 days of completion.
Plan of correction
*All components of the Special Order were completed and submitted to DSS, in its entirety, on April 15, 2021. *The required internal postings were completed on Jan. 11, 2021 and reported to DSS on Jan. 12, 2021. *All components of the Notification listed under 1. (c) were completed on March 9, 2021 to those Guardians and Responsible Parties of those residing at Bickford of Virginia Beach at that time. This was reported to DSS on March 31, 2021. *Four additional recipients, no longer at the Branch on March 9, 2021 but who were at the time that the notification should have been made in January 2021, received the identical notification on April 15, 2021. This brought the Branch into compliance with the Special Order. *Any future DSS requirements of this nature will be electronically scheduled, with a due date, and shared with the RNC, ACC and Divisional Director to assure timely completion.
January 13, 2021Inspection4 violations
Inspection dates
Jan. 13, 2021 , Jan. 14, 2021 , Jan. 15, 2021 , Jan. 28, 2021 and Jan. 29, 2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 01-13-2021 and concluded on 01-29-2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 57. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, criminal background checks and sworn disclosures of newly hired staff, staff schedules, fire drills, fire and health inspection reports, dietary oversight, and healthcare oversight. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-450-F
Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) was reviewed and updated as needed as the condition of the resident changes.
Evidence
  1. Resident #3’s signed physician’s orders labeled ?Hospice IDG Comprehensive Assessment and Plan of Care Update Report? dated 11-12-2020 documented, the resident is on 2L of continuous oxygen at night, and 2L PRN [as needed] during the day.
  2. Resident #3’s current ISP dated 06-15-2020 was not updated to reflect the need for oxygen, per the physician’s order dated 11-12-2020.
  3. Staff #1 and staff #2 acknowledged the resident’s ISP was not updated to reflect the need for oxygen.
Plan of correction
*Residents #3s ISP was updated to reflect the current Provider O2 orders. *The RNC conducted a 100% audit to reconfirm all Provider orders for any Residents on O2 and updated those ISPs, if needed. *The RNC/ACC to audit all ISPs, at the time of admission, to assure that all O2 orders are reflected on the initial ISP.
22VAC40-73-650-B
Based on record review and interview, the facility failed to ensure physician orders, both written and oral, for administration of all prescription and over-the-counter medications, identified the diagnosis or specific indications for administering each drug.
Evidence
  1. Resident #1 and resident #4’s signed physician’s orders did not include a diagnosis or specific indications for ?s cat o s o administering each of the following medications: A. Resident #1’s order dated 11-04-2020 for Pregabalin 150mg; order dated 09-30-2020 for Prednisone 40mg; and order dated 12-02-2020 for Lyrica200mg; and B. Resident #4’s order dated 12-02-2020 for Trulicity .75mg and Vit. D 5,000 units.
  2. Staff #1 and staff #2 acknowledged resident #1 and resident #4’s physician’s orders did not include the diagnosis or specific indications for administering the aforementioned medications.
Plan of correction
*Resident #1 and #4 both had their Physician’s Order Sheets updated to reflect the diagnosis for each medication ordered. *The RNC/ACC conducted a 100% audit of all Physician Order Sheets to assure that all Resident medication orders also contain a diagnosis. *The Physical Examination Form, given to Providers prior to admission, was modified/highlighted to remind the Provider to include a diagnosis for each medication ordered. *All new medication orders will be reviewed by the RNC/ACC/LPN or RMA, prior to sending to the pharmacy, to assure that the orders also contain a diagnosis. *RNC/ACC to audit the Physician Order Sheets monthly to assure that all ordered medications have a diagnosis.
22VAC40-73-680-D
Based on record review and interview, the facility failed to ensure medications are administered in accordance with the physician's instructions.
Evidence
  1. Resident #4 has three (3) separate insulin orders (1 sliding scale & 2 routine). The resident’s signed physician’s orders dated 11-25-2020 documented, “Humalog Kwik Inj 100/ML- Inject per S/S [sliding scale] three times a day: 201-250=2U” 301-350=6U“ 401-450=10U, >450 Contact NP.” The resident’s December 2020 Medication Administration Record (MAR) documented: A. 12-01-2020 at 12:00 PM, blood glucose reading was 346, 8 units of Humalog administered; B. 12-09-2020 at 5:00 PM, blood glucose reading was 158, 2 units of Humalog administered; and C. 12-23-2020 at 8:00 AM, blood glucose reading was 112, 15 units of Humalog administered.
  2. In addition, resident #4’s signed physician’s orders dated 11-25-2020 documented, ?Humalog Kwik Inj 100/ML- Inject 5 units subcutaneously with dinner?? The December 2020 MAR documented Humalog 5 units with dinner not administered fourteen (14) times to include the following dates with the following reasons: A. 12-04-2020 & 12-07-2020 - “withheld per DR/RN orders”; and B. 12-10-2020, 12-11-2020, 12-23-2020, 12-24-2020 & 12-28-2020 - “outside order parameters”. C. Staff #3 stated “personal nursing judgement” was used to hold the routine insulin; and did not notify the physician.
  3. The resident signed physician’s order dated 12-02-2021 documented, “Increase Humalog with breakfast to 10 units.” The December 2020 documented Humalog 10 units was not administered with breakfast on 12-08-2020. The reason: ?? outside order parameters?.
  4. Staff #1 did not provide a physician’s order to hold the 5 units and/or 10 units of Humalog on the aforementioned dates.
  5. Resident #1 current signed physician’s orders dated 09-02-2020 documented ?Aspercreme Pad Lido 4%- Apply to lower back every morning and remove 12 hours later. [Equiv To: Apply at 8AM and Remove at 8PM].? Resident #1’s October 2020 and December 2020 MARs documented staff applied the Aspercreme Pad 4% at 7:00 AM and removed at 9:00 PM.
  6. Resident 1’s signed physician’s order dated 09-30-2020 documented “Prednisone 40mg x6 days PO QAM.” Resident #1’s October 2020 MAR documented Prednisone 40mg was administered 10-03-2020 through 10-07-2020 (5days).
  7. Staff #1 and staff #2 acknowledged resident #1 and resident #4’s aforementioned medications were not administered in accordance with the physician’s instructions.
Plan of correction
*RNC notified the Provider of the LPN’s/Staff #3 decision to withhold the routine insulin due to concerns of Resident #4 becoming Hypoglycemic. The Provider stated that her plan is to D/C all insulin orders for Resident #4 and continue with Trulicity only, affective 3/11/21. *RNC re-educated the LPN/Staff #3 on the need to notify the Provider anytime nursing judgement results in a decision to not follow Provider orders. *There are no other insulin dependent residents residing at Bickford of Virginia Beach, at this time. *In the future, all sliding scale insulin administration is to be double checked by the RNC/ACC/LPN or another RMA prior to administration. *The RNC/ACC will conduct weekly medication audits, utilizing QuickMar, to assure that the sliding scale insulin is being properly administered and signed off by getting a double check prior to administration.
22VAC40-73-680-E
Based on record review and interview, the facility failed to ensure treatments ordered by a physician or other prescriber are provided according to his instructions and documented. The documentation should be maintained in the resident's record.
Evidence
  1. Resident #3’s signed physician’s orders labeled ?Hospice IDG Comprehensive Assessment and Plan of Care Update Report“ dated 11-12-2020 documented, ”02- Oxygen, Reason: Dyspnea, Instructions: Continuous 2L at night, 2L PRN During Day.?
  2. Staff #1 and staff #2 could not provide documentation indicating resident #3 received continuous 2L of oxygen at night in November 2020 and December 2020; nor could staff provide a discontinued order.
  3. Resident #3’s “Hospice IDG Comprehensive Assessment and Plan of Care Update Report” dated 11-12-2020 also documented ?“ the staff do not always remember to place the oxygen on [resident] at night”?
  4. Staff #1 and staff #3 acknowledgement the aforementioned regarding resident #3’s oxygen.
Plan of correction
*The ACC contacted the Provider for Resident #3 and clarified the O2 orders, reviewed those orders with Hospice and then updated the ISP accordingly. * The RNC conducted a 100% audit to reconfirm all Provider orders for any Resident on O2 and updated those ISPs, if needed. *The RNC/ACC then profiled/approved the O2 orders in QuickMar to assure that this service is being provided to Resident *The RNC/ACC then profiled/approved the O2 orders in QuickMar to assure that this service is being provided to Resident #3, and any other Resident on O2, as ordered by the Provider. *The RNC/ACC educated the BFMs/Staff about this change in QuickMar and the need to document that the task was completed. *The RNC/ACC/DIR to conduct weekly medication audits, utilizing QuickMar, to assure that the care is being properly signed off on as ordered by the Provider.