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: Aug. 31, 2021 , Sept. 7, 2021 and Nov. 19, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

A renewal inspection was initiated on 08-31-21 and concluded on 11-24-21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 68. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 4 resident records, 4 staff records, new hire since last inspection, activities calendar, staff scheduled, facility menus, health care oversight, nutritional document, pharmacy report and fire and emergency record submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 11-19-21. An exit interview was conducted with the Administrator and staff on 9-7-21 and a final on 11-24-21, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violations notice issued to be the facility.

Violations:

Standard #:	22VAC40-73-1140-E
Description:	Based on record review and staff interview, the facility failed to ensure within the first month of employment, staff, other than the administrator and direct care staff, who will have contact with residents in the special care unit shall complete two hours of training on the nature and needs of residents with cognitive impairments due to dementia. Evidence: 1 Staff #7?s record submitted on 9-1-21 documented staff with a hire date of 2-1-21. Staff?s record documented .75 hours of cognitive training on 2-3-21. 2. Staff #8?s record submitted on 9-1-21 documented staff with a hire date of 8-3-20. Staff?s record did not include documentation of cognitive training. 3. Staff #1 acknowledged during the final exit, staff #7 and #8 record did not include documentation of the required cognitive training hours.
Plan of Correction:	1.Within 30 days new hires will receive the required number of hours of cognitive training. 2. An audit will be conducted for all non-direct staff hired within the past month to ensure two hours of training on cognitive impairment has been completed. 3. HR Director, Staff Development Coordinator were re-educated on the standard for cognitive impairment training for non-direct care staff. 4. Random audit of training will be conducted biweekly for 30 days to ensure compliance with standard. 5. Audit findings to be reported to QA Committee. Person Responsible: Staff Development Coordinator. HR Director or Designee, Staff Development Coordinator, AL Administrator by December 31, 2021
Standard #:	22VAC40-73-120-A
Description:	Based on record review and staff interview, the facility failed to ensure the orientation and training required per subsections B and C of 22VAC40-73-120 of the regulation shall occur within the first seven working days of employment. Until this orientation and training is completed, the staff person may only assume job responsibilities if under the sight supervision of a trained direct care staff person or administrator for two of four staff record review. Evidence: 1. Staff #7?s record documented staff?s date of hire as 2-1-21. Staff?s record submitted on 9-1-21 did not include documentation of the requirements of subsection B and C of 22VAC40-73-120 of the regulation. 2. Staff #8?s record documented staff?s date of hire as 8-3-20. Staff?s record submitted on 9-1-21 did not include documentation of the requirements of subsection B and C of 22VAC40-73-120 of the regulation. 3. Staff #1 acknowledged during the exit, staff #7 and #8?s record did not include the required orientation and training for new hire.
Plan of Correction:	1. An audit of all new team member files will be conducted one week after onboarding for accuracy. HR department will be notified of any discrepancies. 2. HR Director and Assistant re-educated and Orientation checklist updated. 3. New 22VAC 40-73-180 form implemented to ensure compliance with standards. 4. Audit findings to be reported to QA Committee. 5. Person Responsible: AL Administrator or designee, HR Director or Designee by December 30, 2021
Standard #:	22VAC40-73-250-D
Description:	Based on record review and staff interview, 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 evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it for one of four staff. Evidence: 1. Staff #8?s record documented staff?s tuberculosis assessment date as 9-5-20; staff?s date of hire was documented as 8-3-20. 2. Staff #1 acknowledged during the final exit on 11-27-21, staff?s TB assessment was not completed according the required timeframe.
Plan of Correction:	1. An audit of all new team member files will be conducted one week after onboarding for accuracy. HR department will be notified of any discrepancies. 2. HR Director and Assistant re-educated and Orientation checklist updated. 3. New 22VAC 40-73-180 form implemented to ensure compliance with standards. 4. Audit findings to be reported to QA Committee. 5. Person Responsible: AL Administrator or designee, HR Director or Designee by December 30, 2021
Standard #:	22VAC40-73-260-A
Description:	Based on record review and staff interview, the facility failed to ensure each direct care staff shall maintain current certification in first aid. Each member who does not have current certification in first aide shall receive certification within 60 days of employment. Evidence: 1. Staff #5?s record documented staff?s date of hire as 8-17-20. Staff?s training record submitted on 9-1-21 noted First Aid, CPR, AED training on 7-17-21 and 8-10-21. 2. Staff #6?s record documented staff?s date of hire as 10-12-20. Staff?s training record submitted on 9-1-21 noted First Aid, CPR, AED training on 7-28-21. 3. Staff #1 acknowledged during the final exit on 11-27-21, staff #5 and #6 did not have First Aid training completed according to the required timeframe.
Plan of Correction:	1. All direct care new hires will have CPR/ First Aid completed no later than 60 days after hire date. 2. An audit of AL/MC team members will be conducted to ensure team members current CPR/First Aid status is documented. 3. HR staff re-educated on Standard to ensure that certifications are completed timely and renewals are conducted prior to expiration of certifications for direct care staff. 4. Audit findings to be reported to QA Committee. Person Responsible: HR Director or designee by December 31, 2021
Standard #:	22VAC40-73-260-C
Description:	Based on observation and staff interview, the facility to ensure the list of all staff who have current certification in first aid or CPR in accordance with the regulation, shall be posted in the facility so that the information is readily available to all staff at all times. The listing must indicate by staff person whether the certification is in first aid or CPR or both and must be kept up to date. Evidence: 1. On 11-19-21 during a tour of the facility, while on the second floor, the inspector inquired of staff #1 where the first aid and CPR listing was posted. The listing posted in the frame on the wall in the nursing station was not updated for staff and it was also not updated to include those current with first aid and or CPR. The posted documented was dated 9-25-2019. 2. Staff #1 acknowledged the first aid- CPR listed posted in the nursing station on the second floor was not current for staff and not up to date for those certified in first aid and/or CPR.
Plan of Correction:	1. Updated list was posted during survey on 11/19/21 2. HR re-educated on maintaining current posting of CPR/First Aid list. 4. The current CPR list will be updated monthly and posted promptly. 5. Posting of list will be audited monthly and findings to be reported to QA Committee. Person Responsible: HR Director or designee, AL Administrator by December 31, 2021
Standard #:	22VAC40-73-290-B
Description:	Based on observation and staff interview, the facility failed to ensure the posting of the name of the current on-site person in charge as required per the regulation, was in place in the facility. Evidence: 1. On 11-19-21 at 8:05 a.m. the name of the staff person in charge posted observed was staff #1, who was not in the building. Interview with staff #9, the inspector was informed staff #10 was the staff- person in charge. 2. According to staff #1, the posting was from the previous day. Staff also acknowledged the staff-person in charge when the inspector arrived was not posted.
Plan of Correction:	1. The Person in charge was corrected at the time of the survey. 2. Nursing team re-educated team on Standard and requirement to change sign at end of each shift. 3. PIC sign will be checked each shift to ensure compliance with standard. 4. Person Responsible: AL Administrator/AIT by November 19, 2021
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure the resident?s individualized service plan (ISP) included all assessed needs. Evidence: 1. Resident #1?s individualized service plan (ISP) dated 12-22-20 did not include the resident?s allergy to tape as documented on the resident?s physical examination dated 9-13-20. The ISP documented no known medical/food/environmental allergies. Resident?s physician order sheet (POS) dated 8-31-21 documented physical therapy (PT) evaluation dated 3-3-21; continued skilled physical therapy 3-26-21, 5-26-21, 6-16-21 and 7-22-21. The record included physical therapy notes from 3-3-21 thru 5-20-21. The POS documented occupational therapy (OT) evaluation 3-22-21, clarification order 5-17-21, clarification order 7-23-21 and 8-26-21. Speech therapy (ST) effective on 7-20-21. 2. Resident #4?s uniformed assessment instrument (UAI) dated 8-3-21 documented medication to be administered by facility staff. However, the physician?s order dated 8-31-21 and the July 2021?s medication administration record (MAR) documented resident keep medication at bedside and self- administers Clotrimazole and Preparation H. The UAI laundry need document help needed. The ISP dated 8-3-21 documented resident, ?does not require assistance? and ?resident takes care of own laundry?. The resident?s Oxygen Therapy did not include the oxygen source, delivery device and the flow rate deemed therapeutic for the resident. 3. Staff #1 acknowledged the resident?s ISP did not contain all assessed needs.
Plan of Correction:	1. UAIs and ISPs for residents #1 and 4 were updated to reflect current needs. 2. Audit conducted to ensure all UAI and ISPs reflect the current needs of residents. 3. Staff will be educated on proper completion of UAIs and ISPs. 4. Random quarterly audits will be conducted for six months to ensure UAIs and ISPs are current and includes all assessed needs. 5. Audit findings to be reported to QA Committee. Person responsible: Nurse Manager/ AL Administrator by December 15, 2021
Standard #:	22VAC40-73-680-I
Description:	Based on record review and staff interview, the facility failed to ensure the facility?s medication administration record (MAR) included all of the required information. Evidence: 1. Resident #4?s July 2021 medication administration record (MAR) did not include the initials of direct care staff administering the following medications on the following dates: (a) Lorazepam 1mg on 7-16 and 7-29-21, (b) Nasogel on 7-16-21, (c) Tylenol on 7-16 and 7-29-21, (d) Buspirone 5mg on 7-5-21, (e) Blood pressure information prior to taking Metoprolol Tartate (7-2, 7-6, 7-11 7-16 and 7-30-21), (f) Furosemide on 7-16-21. (g) Lorazepam 1mg on 71- and 7-29-21; Lorazepam 2mg (every 6 hours) on 7-16, 7-18, 7-23, and 7-28-21, (h) Pepcid on 7-2 and 7-6-21, and (i) Imdur on 7-6-21. 2. Staff #1 acknowledged during the exit, resident #4?s MAR did not include initials of the staff administering medications on the aforementioned dates.
Plan of Correction:	1. Audit conducted for AL/MC residents to ensure MAR includes all required information. 3. Staff will be re-educated on ensuring MARs include all required information. 4. Daily audits will be conducted to ensure that MARs have required information. 5. Audit findings to be reported to QA Committee. Person responsible: AL Nurse Manager, AL Administrator by December 1, 2021 and ongoing
Standard #:	22VAC40-73-870-A
Description:	Based on observation and staff interview, 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 11-19-21 during a tour of the facility, the floors in the dining room on the first floor and the third floor was covered with speckles of white paint. 2. The wallpaper on the wall near the entrance of the dining room on the 3rd floor was peeling away from the wall. The railing along the wall above the wall paper was also in need of painting as there were areas where the natural wood was exposed. 3. Staff #1 acknowledged the wallpaper was coming off the wall and the railing needed painting.
Plan of Correction:	1 The wallpaper, railing and floors were cleaned and repaired. 2 A walk through was conducted to ensure that all areas of the building were clean and in good repair. 3. Maintenance was re-educated on ensuring building is clean and in good repair. 4. Walk-throughs of AL areas will occur weekly for 4 weeks and biweekly thereafter with the assigned maintenance tech and the administrator. Maintenance Manager, Technician and AL Administrator or designee. By December 9, 2021
Standard #:	22VAC40-90-40-B
Description:	Based on record review and staff interview, the facility failed to ensure the criminal history record report shall be obtained on or prior to the 30th day of employment for two staff. Evidence: 1. Prior to the 30th day of employment, the facility did not have documentation of the criminal history record report for NH-1; date of hire documented as 3-1-21 and the criminal history report dated 9-1-21. 2. Prior to the 30th day of employment, the facility did not have documentation of criminal history record for NH-2; date of hire documented as 1-4-21 and the criminal history report dated 8-23-21. 3. During the final exit, staff #1 acknowledged the facility did not obtain on or prior to the 30th day of employment a criminal history record for new employees since the date of hire.
Plan of Correction:	1. A full audit of records for AL/MC team members will be conducted to ensure background checks were completed within 30 days for current team members. 2. HR Assistant and HR Director were re-educated on process and standards. 3. HR records of new hires will be audited after each orientation for new team members. 5. Audit findings to be reported to QA Committee. Person Responsible: HR Director or designee, AL Administrator by Date: December 31, 2021