VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Chesterbrook Residences
2030 Westmoreland Street
Falls church, VA 22043
(703) 531-0781

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: Feb. 25, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS.

Comments:

An unannounced renewal study was conducted on 2/25/2020. At the time of entrance 89 residents were in care. The sample size consisted of 10 resident records, five staff records, two volunteer records and three individual interviews. Resident and staff records and other documentation were reviewed. Criminal Background Checks of all staff hired since the previous inspection conducted on 3/11/19 were reviewed. Residents were observed eating breakfast and lunch. Medication administration was observed. Possible violations were reviewed at exit interview. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based upon a review of medication administration records and interview with staff, the facility failed to implement a written plan for medication management verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order and for monitoring medication administration and the effective use of the MARs for documentation. Evidence. The February 2020 MARS for Resident #5 has orders for Novolog Flex Pen 100u/ML, 10u subcutaneously every day before breakfast and Novolog Flex Pen 100u/ML give 2 units if blood sugar is >400 in addition to standing dose. No physician's orders for Novolog are in the record, however the facility received Novolog from the pharmacy. The facility failed to verify there was an order for Novolog and the MARS was not accurately transcribed. Resident #5 did not receive the unprescribed Novolog listed on the MARS. For Resident #6, there was documentation on the MARS that the resident received a 7:00 am dose of Levothyroxine 88mcg on 2/10/2020. Resident #6 was not in the facility on 2/10/2020. The resident had a fall on 2/9/2020 at approximately 6:30 pm and was sent out the hospital immediately. Resident #6 did not return to the facility until 2/11/2020 at approximately 7:00 am.
Plan of Correction:	The staff involved in Resident #5's order verification has been re-educated about the proper procedures when receiving the wrong medication from the pharmacy. An in-service will be conducted with the nursing staff to make sure that proper protocols are followed. The staff involved in Resident #6's documentation has been re-educated on the proper procedure of when a resident has left the community. An in-service will be conducted with all nursing staff to make sure proper protocols are being followed. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) will review all the Medication Administration Records (MARS) of the current residents to ensure accuracy of physician orders. Quarterly in -services with the nursing staff will be done to ensure that documentation errors can be avoided. The DON and ADON will conduct random audits to review resident MARS to ensure an implementation of a written plan for medication management to verify that medication orders have been accurately transcribed to the MARS within 24 hours of receipt of a new order. The DON and ADON will continue with supervision of medication administration.