VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Chesterfield at Brandermill Woods
2100 Brandermill Parkway
Midlothian, VA 23112
(804) 379-7100

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: Oct. 28, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10-28-22 from 2:00 p.m.- 3:20 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 8-19-22 regarding allegations in the area(s) of: Additional Requirements for facilities that care for adults with serious cognitive impairments. Number of residents present at the facility at the beginning of the inspection: 50 Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 Additional Comments/Discussion: The record of the identified resident was reviewed and the resident was observed. Staff were interviewed and the areas of the facility identified in the self-report were also observed. An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov Violation Notice Issued: Yes A copy of this document will be sent to the licensee/provider for signature.

Violations:

Standard #:	22VAC40-73-1150-A
Description:	Based on a self-report received from the facility on 8-18-22 as well as interviews with staff, the facility failed to ensure that doors that lead to unprotected areas shall be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are a part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates. Evidence: -The facility reported that Resident #1, who resides on the memory care unit, eloped from the facility and was found walking on the sidewalk near the front entrance of the facility on 8-18-22 within five minutes. -The administrator stated that the exit door key pad has a 30 second delay before locking (which was observed by the licensing inspector when demonstrated by the administrator) and when the staff member reset the alarm and walked away, the resident opened the door and was able to exit the facility.
Plan of Correction:	An In-service was conducted with staff on 8-18 and 8-19-22 after incident occurred relating to the alarm system, delayed egress mechanism and locking device. A second pressure pad device was installed at the entrance to outside door on 10-26-22. All staff were In-serviced again on the delayed egress mechanisms and locking device. Staff will continue to make rounds every two hours to ensure safety.