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: Oct. 7, 2022 , Oct. 11, 2022 , Oct. 20, 2022 and Oct. 25, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND

Comments:

Type of inspection: Complaint An unannounced complaint inspection was conducted on 10-7-22 (Ar 09:50/ dep12:35 p.m.) The facility census was 71. Record reviewed/staff interviewed/documents reviewed. An exit interview was conducted with the administrator and the acknowledgement form was signed and dated. 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 9-18-22 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: 71 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: 8 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 on-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:

Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on document reviewed and interviews, the facility failed to report to the 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 8-28-22, the Peninsula Licensing Office received a complaint regarding bed bug infestation at the facility. 2. On 10-7-22 during interviews with staff #1, #2 and #9, the facility discovered bedbug in the laundry of a resident and a room in the facility. 3. Staff #2 acknowledged the licensing office was not notified of the incident that affected a resident in the facility.
Plan of Correction:	1. Assisted Living Administrator in Training provided inspector with the incident report that was previously completed but not submitted. 2. Assisted Living Administrator reviewed prior incident reports to ensure that all reports were submitted and acknowledged within the proper timeframe. 3. Assisted Living AIT and team members were re-educated on the notification standards and an alternate team member was identified to ensure reports are submitted timely. 4. An audit of future reportable incidents will be conducted monthly x 2 months to ensure all documentation has been reported timely. 5. Progress of new process will be reported to QA Committee. Person Responsible: AL Administrator by November 1, 2022
Standard #:	22VAC40-73-300-B
Complaint related:	No
Description:	Based on observation and staff interviews, the facility failed to ensure information of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical and mental conditions were documented in the facility?s communication book. Evidence: 1. On 10-7-22, interviews with staff #3 and #4 a request was made by the inspector to review the facility?s communication log regarding a resident?s medication and absence from the facility. 2. The facility?s communication log book did not document resident #1?s absence from the facility. The resident was away from the facility beginning on the evening of 9-13-22 thru 9-22-22. There was no documentation regarding the reason for resident?s absence. 3. Staff #3 acknowledged the communication log book did not document resident #1?s absence from the facility.
Plan of Correction:	1. Nurse manager will educate nursing team on timely and appropriate documentation in communication notebook. 2. Nurse manager re-educated the expectation of daily huddles to include documentation of huddle topics in communication book. 3. Nurse manager will educate on the proper documentation required in the electronic health record. 4. Nurse manager or designee will conduct random audits of EHR charting and documentation in communication books weekly for one month. 5. Progress of new process will be reported to QA Committee. Person responsible: Nurse Manager / AL Administrator and or designee by November 30, 2022
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure medication administration record (MAR) included all of the required information. Evidence: 1. On 10-7-22, the initials of staff administering medications was observed to be missing on resident #1?s September 2022 medication administration record (MAR). This document which was provided to the inspector by staff #1 was also reviewed with staff #1. 2. Interviews with staff #4, #5 and #6, stated the resident was transferred out of the system. The medication record did not include documentation of the resident?s transfer. The MAR did not include staff initials on 9-18-22 thru 9-22-22 for 8:00 a.m. medications (Norvasc, Multi-Day vitamin, Vitamin C and Vitamin D3. The MAR did not include staff initials for blood pressure information on 9-3-22, 9-18 thru 9-21-22 and 9-26-22. Weekly skin assessment on 9-19-22 did not include staff initials. 3. Staff acknowledged the aforementioned resident?s MAR did not include the initials of staff administering medications.
Plan of Correction:	1. Nurse manager will educate nursing staff on proper documentation in: IDT notes, MARs, skin assessments and vitals for residents on LOA. 2. Charge nurses will review MARs each shift to ensure proper completion of MARS. 3. Nurse manager or designee will conduct random audits of IDT notes and MARs to ensure proper documentation and administration of meds weekly for 4 weeks. 4. Progress of new process will be reported to QA Committee. Person responsible: Nurse Manager / AL Administrator and or designee by November 30, 2022
Standard #:	22VAC40-73-870-A
Complaint related:	Yes
Description:	Based on documents provided and staff interviewed, the facility failed to ensure the facility was kept free of infestations of insects and vermin. The grounds shall be kept free of their breeding places. Evidence: 1. On 10-7-22, during a complaint inspection of bedbugs in the facility, the inspector was provided documentation of the facility?s activities regarding bedbugs in the facility, to include the use of dogs.
Plan of Correction:	1. Assisted Living AIT immediately coordinated with Director of Environmental Services for plan of treatment for pest elimination at the time of incident. 2. Assisted Living Administrator increased frequency of visits from pest vendor for next three months. 3. Environmental Services Director will make random checks of rooms monthly for 3 months. 4. Environmental Services Director will re-educate housekeeping team to identify and report any findings during normal duties. 5. Progress of new process will be reported to QA Committee. Person responsible: AL Administrator by November 30, 2022