VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Newport News Baptist Retirement Community DBA The Chesapeake
955 Harpersville Road
Newport news, VA 23601
(757) 223-1635

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: Sept. 26, 2019 and Sept. 27, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

An unannounced renewal inspection was conducted by two Licensing Representatives on September 26th from 8:05 a.m. to 4:47 p.m. and September 27th from 9:21 a.m. to 12:26 p.m. There were 58 residents in care. The following was discussed during the inspection: Activity scheduled hours, Relias training, emergency preparedness review, self-administration of medications, supervision of maintenance items, medication labeling, discharge statements, and fire inspection reports. Please submit your ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it within 10 calendar days. The plan of correction must indicate how the violation will be or has been corrected. The plan of correction must include: 1. Step(s) to correct the noncompliance with the standard(s) 2. Measures to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative measures. If you have any questions, please contact your inspector Alexandra Poulter at 757-613-5133 or alexandra.poulter@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-210-F
Description:	Based on record review and interview, the facility failed to ensure at least two of the required direct care staff training hours focused on infection control and prevention, and four of the required hours focused on topics related to residents? mental impairments. Evidence: 1. On 09-26-19 during record review, the following staff records did not document four hours of annual mental impairment training: a. Staff #3?s date of hire was 08-13-18. Staff #3?s record documented two of the required four hours of mental impairment training from 08-13-18 through 08-12-19. b. Staff #6?s date of hire was 05-18-15. Staff #6?s record documented zero of the required four hours of mental impairment training hours from 05-18-18 through 05-17-19. 2. Staff #5 observed and confirmed the aforementioned staffs? records did not contain the required training hours.
Plan of Correction:	1) Staff #3 and Staff #6 will be scheduled to complete required 4 hours of mental impairment training and required 2 hours of infection control. 2) Employee training files will be checked on a monthly basis to ensure infection control and prevention and mental health training is completed by deadlines to remain in regulatory compliance. 3) AL Administrator, or designee, Staff Development Coordinator and Human Resources.
Standard #:	22VAC40-73-325-B
Description:	Based on record review and interview, the facility failed to ensure the fall risk rating was reviewed and updated after a fall. Evidence: 1. During record review on 09-26-19, resident #1 had a fall on 09-15-19 documented on the ?Interdisciplinary Notes?. The last fall risk rating documented in resident #1?s record was dated 05-18-19. 2. Resident #3 had a fall on 08-18-19 per an incident report received by the regional licensing office; however, the fall risk rating observed was dated 09-08-19. 3. Resident #4 had falls documented on 05-22-19, 06-09-19, 07-02-19. and 07-31-19 on the Individualized Service Plan (ISP); however, the fall risk rating observed was dated 09-08-19. 4. Staff #1 observed and confirmed aforementioned information.
Plan of Correction:	1) Fall risk ratings were updated for resident?s #1, #3, and #4. 2) Fall risk ratings will be completed after each fall and every 6 months to remain in regulatory compliance. Clinical management team will audit periodically for completeness. 3) AL Administrator, or designee, LPN
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview, the facility failed to ensure the comprehensive Individualized Service Plan (ISP) included a description of identified needs based on the Uniform Assessment Instrument (UAI). Evidence: 1. On 09-26-19 during record review, resident #5?s UAI dated 01-28-19 assessed that the resident requires dressing assistance by human help/physical assistance (HH/PA); however, a review of the resident?s ISP dated 01-28-19 documented the resident utilizes a mechanical device (mechanical help) to assist with dressing. 2. Staff #1 confirmed the ISP was correct and that the mechanical device used by resident #5 is a reacher/grabber tool.
Plan of Correction:	1) Resident #5?s UAI/ISP was updated to reflect current dressing needs. 2) Residents UAI/ISP will reflect all needs and will be updated with any significant change and yearly to remain in regulatory compliance. Monthly audits to be completed by clinical management team to ensure needs are met. 3) AL Administrator, or designee, LPN
Standard #:	22VAC40-73-450-F
Description:	Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) was updated as needed as the condition of the resident changed. Evidence: 1. During resident #5?s record review, a physician?s order dated 06-24-19 documented physical therapy (PT) evaluation and treatment for generalized muscle weakness was observed. Additionally, in the record was documentation of the resident starting PT on 07-03-19. The resident?s PT services were certified for 08-28-19 through 10-22-19. 2. Resident #5?s most current ISP dated 01-28-19 did not include the addition of PT. 3. Staff #1 and staff #4 observed and confirmed resident #5?s current therapy services were not included on resident #5?s most current ISP.
Plan of Correction:	1) Resident #5?s UAI/ISP was updated to reflect PT treatment. 2) Residents UAI/ISP will reflect all needs and will be updated with any significant change and yearly to remain in regulatory compliance. Monthly audits to be completed by clinical management team to ensure needs are met. 3) AL Administrator, or designee, LPN
Standard #:	22VAC40-73-660-B
Description:	Based on observation and interview, the facility failed to ensure that residents were permitted to keep their own medication in an out-of-sight place in their room if the Uniform Assessment Instrument (UAI) has indicated that the resident is capable of self-administering medication, and the medication was stored so that they are not accessible to other residents. Evidence: 1. During facility tour on 09-26-19 with staff #1, Adult Glycerin Suppositories (50 count) and Sore Throat Spray were observed in resident #7?s bathroom. Resident #7?s current UAI assessed the resident as being dependent in medication administration. Additionally, during the tour with staff #2, a blue and orange pill was observed in resident #6?s bathroom. Resident #6?s current UAI assessed the resident as being dependent in medication administration. 2. Staff #1 observed and confirmed the Adult Glycerin Suppositories and Sore Throat Spray located in resident #7?s bathroom. Staff #2 observed and confirmed the blue and orange pill located in resident #6?s bathroom. Staff #1 confirmed both residents? most current UAIs documented both residents were dependent in medication administration.
Plan of Correction:	1) Medications were removed immediately from resident?s #6 and #7?s bathroom. 2) Residents, who wish to self-administer medications, will have a self-administration assessment completed, and an order will be obtained from physician to self-administer medications. Medications will be secured in an out of sight place for residents who self-administer. UAI will be updated to reflect. Room checks will occur periodically to ensure there are no medications or any dietary supplements in resident?s rooms by clinical management team. Education provided to nursing staff to remove any medications or dietary supplements from rooms of resident?s who do not self-administer medications and Education and notifications will be provided families to pick up medications. 3) AL Administrator, or designee, LPNs.
Standard #:	22VAC40-73-680-I
Description:	Based on observation and interview, the facility failed to ensure the Medication Administration Record (MAR) included the initials of direct care staff administering the medications. Evidence: 1. On 09-26-19 during record review, the July 2019 MAR did not contain the initials of direct care staff who administered the following medications: a. Resident #1?s Systane Gel 0.4% -0.3% on 07-26-19 at 12 p.m.; Bacitracin 500 unit/gram topical ointment on 07-09-19 3:00 p.m. ? 11:00 p.m., on 07-12-19 3:00 p.m. ? 11:00 p.m., on 07-25-19 3:00 p.m. ? 11:00 p.m., and on 07-07-19 7:00 a.m. ? 3:00 p.m.; and b. Resident #2?s Clopidogrel 75 mg, Enteric Coated Aspirin 81 mg, and Flovent HFA 110 mcg/actuation on 07-18-19 at 8:00 a.m.; Melatonin 5 mg on 07-14-19 and 07-31-19 at 9:00 p.m.; Simvastatin 20 mg on 07-14-19 and 07-31-19 at 10:00 p.m.; Trazodone 50 mg on 07-14-19 and 07-31-19 at 10:00 p.m. 2. Staff #1 observed and confirmed the aforementioned were not documented on the July 2019 MARs of resident #1 and resident #2.
Plan of Correction:	1) MAR?s for resident?s #1 and #2 were reviewed for completeness and accuracy. Nurses for July 2019 no longer work for community. Unable to correct holes in MAR. 2) MAR will be checked at end of shift by off-going nurse/RMA. Re-education provided to nursing staff regarding medication administration and documentation. MAR will be audited weekly by clinical management team to remain in regulatory compliance. 3) AL Administrator, or designee, LPN, RMA.
Standard #:	22VAC40-73-970-E
Description:	Based on record review and interview, the facility failed to ensure the record of the required fire and emergency evacuation drill included the number of residents participating, weather conditions, and time it took to complete the drill. Evidence: 1. On 09-26-19, fire and emergency evacuation drills information was reviewed. The fire drills conducted did not document the number of residents that participated, weather conditions, and time it took to complete the drill for the following dates: 06-10-19, 07-24-19, 07-25-19, 08-07-19, 08-12-19, 09-16-19, and 09-18-19. 2. Staff #1 observed and confirmed the drills did not contain the aforementioned information.
Plan of Correction:	1) Fire and Emergency Evacuation drills for October updated with number of residents that participated, weather conditions, and time it took to complete drills. 2) Forms updated to include number of residents that participated, weather conditions, and time it took to complete drills. Updated forms will be used to conduct monthly drills to remain in regulatory compliance. 3) AL Administrator, or designee, Director of Building and Grounds, Maintenance department.