Newport News Baptist Retirement Community DBA the Chesapeake
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based on 26 Google reviews
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What this means for your family
This facility is a strong option for highly functional seniors seeking independent living in a renovated environment. However, if your loved one requires high-acuity healthcare or memory care, you must investigate the nursing response times and staffing levels, as multiple families have reported significant delays in care and communication breakdowns.
Google Reviews
Google Reviews
26 reviews on Google“Families should note that while some reviewers praise the updated facility and friendly staff, there are serious allegations regarding nursing incompetence and slow response times to call buttons. While the community is well-regarded for independent living, multiple reviewers have expressed significant concerns regarding the quality of care and communication during transitions to assisted living.”
Quality Themes
Tap a score for detailsStrengths
- Updated and nice facility decor
- Friendly and professional staff members
- Secure environment with on-site security
- Strong reputation for independent living
Concerns
- Slow nursing response to call buttons (mentioned by 2 reviewers)
- Poor communication from administration regarding admissions
- Inadequate staffing levels (mentioned by 2 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 26 analyzed
How They Respond to Reviews
This facility responds to some reviews.
Questions for Your Tour
- 1The facility looks beautifully updated and well-maintained; could you tell us more about the recent decor improvements?
- 2We are interested in the assisted living program; how do you ensure that nursing staff are able to respond promptly to call buttons during the night shifts?
- 3What specific protocols do you have in place for medication management to ensure everything is handled accurately and safely?
- 4How does the administration keep families updated and involved in the communication process regarding a resident's care and admissions?
- 5Could you describe the daily activity calendar and how you tailor social engagement for residents in the memory care wing?
- 6In the event of a medical emergency, what is the immediate process for contacting physicians or coordinating with outside emergency services?
Personalized based on this facility's data
Key Review Excerpts
“The dining room and lobby have been renovated and are very nice!”
“I had a great couple of initial phone calls and meeting with admissions regarding my dad moving to the facility but I have not heard anything back since.”
“Generally the staff is super friendly BUT the nurses are very slow to respond to the call button. I am currently waiting for medicine for my father that he first rang the bell for almost two hours ago.”
State Inspection History
State Inspections
Source: VA State Licensing Agency
Jul 29, 2025Routine
Type of inspection: Renewal An unannounced renewal inspection was conducted on 7-29-25 (Ar. 07:10 a.m./ Dep 14:15 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: 73 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: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 8 Observations by licensing inspector: breakfast meal, medication observation, emergency preparedness, call bells/water temperature. 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
Based on observation, documents reviewed, and staff interviewed, the facility failed to ensure medications ordered for PRN
Based on observation and staff interviewed, the facility failed to ensure the hot waters available to residents were maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F. Evidence: 1. On 7-29-25 during a tour of the facility with staff #8, the water temperature at the sinks in the bathroom in room #320 was 103 degrees F; room #303 was 103 degrees F. and room #220 was 102 degrees F. 2. Staff #8 acknowledged the water temperatures did not meet the required range of 105 degrees to 120 degrees F.
Apr 29, 2025RoutineCleanReport
Type of inspection: Monitoring An unannounced non-mandated monitoring inspection was conducted on 4-29-25. (Ar. 08:20 a.m./Dep 10:20 a.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: 64 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (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
Oct 7, 2024Routine
Type of inspection: Renewal An on-site renewal inspection conducted on 10-7-24. (AR 07:05 a.m./Dep 17:35 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: 71 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: 9 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 11 Observations by licensing inspector: medication pass (AL and SCU), breakfast meal, emergency preparedness (water/food,) water temperature- activity 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
Based on document reviewed and staff interviewed, the facility failed to ensure within four months of the starting date of employment direct care staff shall attend at least 10 hours of training in cognitive impairment. Evidence: 1. On 10-7-24, staff #6?s training documentation provided did not include 10 hours of training in cognitive impairment. Staff?s date of hire noted as 4-22-24. 2. Staff #1 acknowledged, staff #6 did not have 10 hours of training in cognitive impairment.
Based on document reviewed and staff interviewed, the facility failed to ensure orientation and training required in subsections 22VAC40-73-120-B and 22VAC40-73-120-C occurred 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. Evidence: 1. On 10-7-24, staff #6?s record did not include documentation of having received orientation and training in the required sections of the standards, 22VAC40-73-120-B and 22VAC40-73-120-C. The document provided to the inspector did not include documentation of the required orientation and training. Staff?s date of hire noted as 4-24-24. 2. Staff #1 acknowledged staff #6 did not have documentation of orientation and training requirements within the first seven working days of employment.
Based on document reviewed and staff interviewed, the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff who are licensed health care professionals or certified nurse aides shall attend at least 12 hours of annual training. Evidence: 1. On 10-7-24, staff #4 did not have documentation of annual training. Staff?s date of hire noted as 7-6-20. 2. Staff #1 acknowledged, staff #4 did not have documentation of annual training requirements.
Based on document 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 reside in the facility, at least four of the required hours shall focus on topics related to the resident?s mental impairments. Evidence: 1. On 10-7-24, staff #4?s training document provided did not include at least two hours of infection control neither the required four hours of mental health impairments training. 2. Staff #1 acknowledged, staff #4 did not have documentation of the required training.
Based on interview, the facility failed to ensure each staff person required to be evaluated annually submitted the results of a risk assessment, documenting the individual was free 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 consist with it. Evidence: 1. On 10-7-24, staff #4, did not have documentation of an annual TB assessment. Staff?s date of hire noted as 7-6-20. 2. On 10-7-24, staff #5, did not have documentation of an annual TB assessment. Staff?s date of hire noted as 8-13-18. 3. Staff #1 acknowledged staff #4 and #5 did not have documentation of an annual TB assessment documenting that the individuals were free of TB in a communicable form.
Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions or care needs. Evidence: 1. On 10-7-24, a review of resident #9?s October 2024 medication administration record ( MAR
Based on record reviewed and staff interviewed, the facility failed to ensure a risk assessment for tuberculosis (TB) was completed annually for a resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. On 10-7-24, a review of resident # 4?s record with staff #2 and #7 did not include an annual TB assessment. The assessment in the record was dated 3-23-23. The resident?s date of admit noted as 2-1-21. 2. Staff #1, #2 and #7 acknowledged, resident #4 did not have evidence of an annual assessment for TB.
Based on record reviewed and staff interviewed, the facility failed to ensure, either directly or indirectly, that the health care service needs of a resident was met. Evidence: 1. On 10-7-24, a review of resident #2?s record with staff #3, the resident?s admission physical dated 5-10-24 noted evaluation for Physical Therapy/Occupational Therapy (PT/OT). Staff #5 search the facility?s system and was not able to locate an occupational or physical therapy evaluation for resident #2. 2. Staff acknowledged the resident did not receive physical or occupational therapy.
Based on record reviewed and staff interviewed, the facility failed to ensure no medication, dietary supplement, diet, medical procedures, or treatment was started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter and sample medications. Evidence: 1. On 10-7-24, resident #8?s October 2024 medication administration record ( MAR
Aug 26, 2024Complaint
Type of inspection: Complaint An unannounced complaint inspection was conducted on 8-26-24. (Ar 06:03 a.m./Dep 08:25 a.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 8-5-24 regarding allegations in the area of staffing and supervision and resident care and related services. 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. Tour of scu and ALF units Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 6 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 allegations of non-compliance with standard(s) or law. However, violation 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
Based on observation and staff interviewed, the facility failed to ensure the findings of the most recent inspection of the facility was posted. Evidence: 1. On 8-26-24, the most recent inspection for the facility was not posted when the inspector checked the binder in the area where the inspection is posted for the public. 2. Staff #2 was informed of the inspector?s findings and went with the inspector to the area where the facility?s inspection is kept. Upon opening the binder, the last inspection in the binder was a Renewal inspection dated 9-23-22. 3. Staff 1 and #2 acknowledged the recent inspection for the facility was not posted on the morning of 8-26-24.
Mar 27, 2024Complaint
Type of inspection: Complaint An unannounced complaint inspection was conducted on 3-27-24 by two inspectors from the Peninsula Licensing Office (PLO) and a nurse consultant from home office. (Ar: 09:26 a.m./dep: 18:25 p.m.) on day one. Day two conducted by the assigned licensing inspector from the PLO, Ar: 09:15 a.m./Dep: 14:35 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 2/28/24 regarding allegations in the resident care and related services and resident accommodations and related provisions. Number of residents present at the facility at the beginning of the inspection: 73 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: 4 Number of staff records reviewed: Number of interviews conducted with residents: 1 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 were valid 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
Based on observation and staff interview, the facility failed to ensure the facility?s plan for proper disposal of medication was conducted. Evidence: 1. On 3-27-24, medication for twenty-four residents: twenty current residents and four discharged (May, August, October, and December 2023) were observed in a cabinet in the nurse?s station in the facility?s safe, secure unit. There were 131 non-controlled medications of various medications ranging from pills, creams, inhalers, ear drops, patches, eyedrops, enemas, cough syrups, anti-diarrheal, nasal sprays, and ointments, etc., that had not been destroyed per the facility?s policy for destruction of non-controlled medications. There were two residents-controlled medications (Alprazolam), that remained on the medication cart that was required to be destroyed. 2. Staff #3 acknowledged the medications observed were not destroyed as required per the facility?s policy.
Based on documents reviewed and staff interviewed, the facility failed to ensure the resident?s record contained the physician?s or other prescriber?s signed written order. Evidence: 1. On 3-27-24, the facility?s ?INR (International Normalised Ratio) Record? for resident #1, #2 and #3, did not include the prescriber or physician?s signature and date for multiple days for new orders for anticoagulation medications. Resident #4?s record did not have signed orders for the faxed memo dated 2-15-24 sent to the facility from an outside clinic documenting resident #4?s anticoagulant ?Warfarin? information. 2. The facility?s physician order sheet (POS) for anticoagulation orders for residents #1, #2, #3 and #4 did not have documentation of the physician or prescriber?s date and signatures during the month of February and March 2024. 3. The facility?s ?Physicians Orders-Policy? noted, ?the resident?s record shall contain the physician?s or other prescriber?s written order or dated notation or the physician?s verbal order?All verbal orders will be reviewed and signed by the physician within 10 working days?. 4. Staff #1, #2 and #3 acknowledged the physician?s orders for anticoagulant for residents #1, #2, #3 and #4 were not signed and date.
Based on observation and staff interviewed, the facility failed to ensure medication storage area was locked. Evidence: 1. On 3-27-24, medications stored in a cabinet with a glass front in the third-floor nursing station were observed to be unlocked. Staff #2 was observed reaching under a bicycle lock to open the door to the medication cabinet. There was a total of forty-seven (47) non-controlled medications of various medications ranging from pills, creams, inhaler, ear drops, patches, eyedrops, enemas, cough syrup, nasal spray, and ointments. One medication, Calcitonin was available but not refrigerated as required. All medications were located on two shelves in the cabinet that had a bicycle lock attached. The apparatus did not lock the cabinet as it allowed access to the cabinet without a key or code. Photograph was obtained on this date. 2. The medications were for ten residents currently in the facility and two residents that expired in October and November 2023. Three medications (Mucinex, Vitamin D3 and AZO) did not have resident?s name. 3. On the same floor, another resident?s Allopurinol medication was observed on top of the medication cart located in the hallway near the nurse?s station entrance. There was no staff member present. 4. Staff #2 acknowledged the medications observed were not stored in a locked area.
Based on observation and staff interviewed, the facility failed to ensure hazardous materials was stored so that they are not accessible to other residents. Evidence: 1. On 3-37-24 during a tour of the facility, a white container labeled ?Drug Buster? was observed on a medication cart in the hallway. The cart was not attended by a staff person. Staff #1 was inquired about the use of the ?Drug Buster? container. Staff stated it was used by med staff to destroy medications. The medication is dissolved once it is placed in the container. Staff was inquired if it was safe for the container to be on the cart. Staff stated it perhaps should not be because of the chemical in the container. 2. The facility?s medication management policy did not include use of the ?Drug Buster? container when describing disposal of facility medications.
Aug 14, 2023Routine
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
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.
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.
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.
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
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.
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.
Oct 7, 2022Complaint
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
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.
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.
Based on record reviewed and staff interviewed, the facility failed to ensure medication administration record ( MAR
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.
Aug 31, 2022Routine11Report
Type of inspection: Renewal An unannounced renewal inspection was conducted by two inspectors on 8-31-22 (Ar 07:40/dep 5:20 p.m.) The facility census was 68. A tour of the facility was conducted, a medication pass observation was conducted, emergency preparedness items reviewed, including the first aid kits; resident and staff interviews and records were reviewed, the breakfast meal on the assisted living unit was reviewed. A preliminary exit meeting was conducted with the administrator, the administrator in training, the social work director, nursing director and a staff from staff development. Requested documents were asked to be sent by close of business on 9-1-22 (facility computer system for training records not working properly). The acknowledgement form was signed and dated by the administrator. The final exit meeting will be scheduled. 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
Based on record reviewed and staff interviewed, the facility failed to ensure all requirements were met when private duty personnel who are not employed by a licensed home care organization provide direct care or companion services to resident in an assisted living facility. Evidence: 1. On 8-31-22, the record for the private duty companion for resident #8 did not document the frequency of services to be delivered to the resident. The orientation checklist was not signed by the private duty companion. There was no criminal history report in the record for the companion. 2. On 8-31-22, staff #2 acknowledged the facility did not have all of the required information and documentation for the private companion for resident #8.
Based on records reviewed and staff interviewed, the facility failed to ensure the subsequent tuberculosis (TB) evaluations and reports were signed and dated by a qualified evaluator for four individuals. Evidence: 1. On 8-31-22, staff 2 and #5?s subsequent tuberculosis (TB) screening dated 2-3-22 was not signed by a qualified evaluation. Staff #6?s subsequent TB screening dated 2-1-22 and Staff #10?s subsequent TB screening dated 1-26-22 was not signed and dated by a qualified evaluator. 2. On 8-31-22, staff #2 acknowledged the aforementioned individuals subsequent TBs were not signed and dated by a qualified evaluator.
Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions or care needs. Evidence: 1. On 8-31-22, resident #3?s August 2022 medication administration record ( MAR
Based on record reviewed and staff interviewed, the facility failed to ensure a risk assessment for tuberculosis (TB) was completed annually for a resident as evidenced by the completion of a current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. On 8-31-22, resident #5?s tuberculosis information was dated 9-14-17; resident?s date of admission noted as 9-15-16. 2. On 8-31-22, resident #1?s record did not have documentation of an annual risk assessment for TB as required. 3. On 8-31-22, staff #3 and #4 acknowledged the aforementioned residents? record did not have documentation of a current TB assessment.
Based on record reviewed and staff interviewed, the facility failed to ensure the fall risk rating was reviewed and updated at least annually. Evidence: 1. On 8-31-22, resident #1?s record did not include the most recent fall risk rating. The risk rating in the record was dated 5-10-21. 2. On 8-31-22, staff #4, acknowledged the aforementioned residents? fall risk rating was not updated annually as required.
Based on record review and staff interview, the facility failed to ensure for private pay individuals the uniform assessment instrument ( UAI
Based on record review and staff interview, the facility failed to ensure the resident?s individualized service plan ( ISP
Based on record reviewed and staff interviewed, the facility failed to ensure when hospice care is provided to a resident, the assisted living and the licensed hospice organization shall communicated and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan ( ISP
Based on document reviewed and staff interviewed, the facility failed to ensure when any portion of an assisted living facility is subject to inspection by Virginia Department of Health, the facility shall be in compliance with those regulations as evidenced by an initial and subsequent annual reports from the Virginia Department of Health. Evidence: 1. On 8-31-22, the facility health inspection report was dated 2-17-21. 2. Staff #1 acknowledged the facility did not have a current health inspection.
Based on observation, record reviewed and staff interviewed, the facility failed to ensure when medication aides administer the PRN
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 a staff. Evidence: 1. Prior to the 30th day of employment, the facility did not have documentation of the criminal history record report for staff #9. Staff?s date of hire documented as 8-30-21 and the criminal history report dated 8-31-22 2. On 8-31-22, staff #1 acknowledged the facility did not obtain on or prior to the 30th day of employment a criminal history record for a new employee.
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