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. 14, 2023 , Aug. 15, 2023 and Aug. 23, 2023

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 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal An unannounced on-site renewal inspection was conducted on 8-14-23 (Ar 08:35 /dep 17:35 p.m.) and 8-15-23 (Ar 09:45/ dep 14:35). The facility census on 8-14-23 was 71. A tour of the facility was conducted, a medication pass observation was conducted, emergency preparedness items reviewed, including the first aid kit, water temperature and emergency water and food; resident and staff interviews and records were reviewed, A preliminary exit meeting was conducted with the administrator and nursing director on day 1 and with the administrator only on day 2. The Acknowledgement Form was signed and dated on each day of the on-site inspection. 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:

Standard #:	22VAC40-73-1140-E
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure within the first month of employment, staff other than the administrator and direct care staff who have direct contact with residents in the special care unit shall complete two hours of training on the nature of and needs of residents with cognitive impairments relevant to the population in care. Evidence: 1. On 8-15-23, staff #4?s record did not have documentation of cognitive training within the first month of employment. Staff?s date of hire noted as 3-13-23. 2. Staff #1 acknowledged the staff?s record did not have documentation of required cognitive training.
Plan of Correction:	1. Staff Development Coordinator will ensure that CARES training is presented at orientation and completed by all team members no later than the first week of employment. 2. Staff Development Coordinator will review Relias Training Program every two weeks to ensure completion of assigned CARES training and will notify immediate supervisor if not complete. 3. Assisted Living Administrator will also conduct periodic checks of completion of training for those with cognitive impairment. 4. Progress of new process will be reported to QA committee Person Responsible: Staff Development Coordinator and AL Administrator by September 28, 2023
Standard #:	22VAC40-73-310-H
Description:	admit or retain individuals with any prohibitive conditions or care needs. Evidence: 1. On 8-14-23, resident #1, physician order noted the resident is prescribed Ativan and Citalopram. The record did not have documentation of a psychotropic treatment plan. 2. Resident #3?s physician order noted the resident is prescribed Prozac. The record did not have documentation of a psychotropic treatment plan. 3. Resident #5?s, physician order noted the resident is prescribed Seroquel, Lorazepam and Zoloft. The record did not have documentation of a psychotropic treatment plan. 4. On 8-14-23, staff #2 acknowledged the facility did not have a treatment plan for- psychotropic medication prescribed for the residents. 5. Staff #1 acknowledged the treatment plan for residents #1 and 3 were not available prior to 8-15-23.
Plan of Correction:	1. Nurse manager and Memory Care supervisor will audit all resident?s psychotropic medication orders and plan using the most current Psychotropic Medication Order Report by Classification. Any missing psychotropic treatment plan will be requested from provider and tracked by manager / supervisor until received. 2. Nurse manager will re-educate nursing staff on how to identify medications that require psychotropic treatment plans and new Psych binder process. 3. Nurse manager, MC Supervisor, Director of Social Services, and AL Administrator will review current Psychotropic Medication Order Report by Classification weekly at AL RISK meeting as new oversight practice. 4. Progress of new processes will be reported to the QA Committee. Person Responsible: Nurse Manager / AL Administrator by September 30, 2023
Standard #:	22VAC40-73-610-B
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure menus for meals and snacks for the current week was dated and posted in an area conspicuous to residents. Evidence: 1. On 8-14-23 during a tour of the facility with staff #2, the breakfast menu and snack menus were not posted for the week. 2. Staff #10 acknowledged the snack menu was not posted for the safe, secure unit. Staff #4 acknowledged the breakfast and snack menu was not posted for the residents receiving meals in Pier 57.
Plan of Correction:	1. Associate Director and Healthcare Supervisor for Culinary will conduct a thorough review of current menu, ensuring that it accurately reflects the snacks and meals that are offered and will be posted weekly. 2. Associated Director and Healthcare Supervisor for Culinary will provide comprehensive training to all training that will focus on the importance of accuracy and adherence to the posted menu and snack options. 3. Assisted Living Administrator will conduct periodic checks for review of the posting and accuracy of the meals and snacks. 4. Progress of new process will be reported to QA Committee. Person responsible: Associate Director of Culinary / Healthcare Supervisor by September 30, 2023
Standard #:	22VAC40-73-650-B
Description:	Based on observation, record reviewed, and staff interviewed, the facility failed to ensure that physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall identify the diagnosis, condition or specific indications for administering each drug. Evidence: 1. On 8-14-23, during the medication pass observation with staff #3, resident #1?s August 2020 medication administration record (MAR) noted resident is being administered Losartan. The MAR did not include a diagnosis, condition or specific indication for this drug. 2. A review of the physician?s orders conducted with staff #2 did not include a diagnosis, condition, or specific indication for this drug.
Plan of Correction:	1. Nurse Manager and Memory Care supervisor will audit all resident?s orders for diagnosis indication by department. Any missing diagnosis will be requested from provider and tracked by manager / supervisor until received and order corrected. 2. Nurse Manager will re-educate all nursing staff on requirement for a diagnosis for all orders. 3. Random audits will be conducted after re-education by Nurse manager and MC supervisor 4. Nurse manager, MC Supervisor, Director of Social Services, and AL Administrator will conduct weekly review of resident?s orders at RISK meeting as new oversight practice. 5. Progress of new processes will be reported to the QA Committee. Person Responsible: Nurse Manager / AL Administrator by September 30, 2023
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation and staff interviewed, the facility failed to ensure the storage of medications area was locked. Evidence: 1. On 8-15-23 a check of the water temperature and signaling system on the safe, secure unit with staff #9 was conducted in room #2. There was no response to the signaling system, and staff #6 and #7 was asked why there was no response to the signaling system for room #2. 2. The ?Sara phone? was not on the staff person and staff did not know the signaling device had been activated. 3. Staff #6 provided the ?Sara phone? to staff #7 from the medication storage cart located near the nursing station. The medication cart that staff #7 obtained the ?Sara phone? was observed to be unlocked.
Plan of Correction:	1. Memory Care Supervisor will conduct re-education and review of The Chesapeake?s medication storage policy. 2. 3. AL Administrator will conduct periodic checks of medication cabinet throughout the day to ensure medication cart is locked and in compliance with policy. 4. Memory Care Supervisor will ensure staff maintains communication device on their person. 5. AL Administrator will perform random call bell test throughout the day and check response times across different shifts. 6. Progress of new processes will be reported to the QA Committee Person responsible: AL Administrator/Memory Care Supervisor by September 30, 2023
Standard #:	22VAC40-73-860-G
Description:	Based on observations and staff interviewed, the facility failed to ensure the 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 8-15-23 during a tour of the facility with staff #9, the following water temperatures were observed: (a) The activity room sink on the first floor across from room #111 was 122.8 F, (b) bathroom in #109 was 122.8 F, (c) bathroom in #206 was 121.0 and (d) bathroom in #209 was 121.9. 2. Staff #9 and #1 acknowledged the water temperatures were not in the required range.
Plan of Correction:	1. Buildings & Grounds Director and Buildings & Grounds Manager will review the weekly temperatures taken in each of the Assisted Living resident rooms by the B&G Higher Levels of Care technician. 2. All temperatures that are outside the permitted range 105 ? 120 will be noted and addressed appropriately. 3. Random audits will be conducted by the Assisted Living Administrator or designee monthly for 1 quarter. 4. Progress of new process will be reported to the QA committee. Person responsible: B&G Manager / B&G Director / AL Administrator by September 30, 2023