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: May 8, 2023

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 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

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: LI entered the facility at 8:45 am on 5/8/2023 and exited oat 4:15 pm on 5/8/2023. 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: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed medication administration. LI observed residents engaging in activities. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-680-B
Description:	Based upon observation, the facility failed to ensure that medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. Evidence: 1. On 5/8/2023 at approximately 9:30 am LI observed staff #5 pour medications for Resident #3 into a cup for administration and take the medications to the room of the resident. LI observed Staff #3 not administering the poured medications to Resident #3 as Resident #3 was in the bathroom. LI observed Staff #3 put the poured medications into the top right drawer of the medication cart. 2. At approximately 10:05 am on 5/8/2023, LI observed Staff #5 administer pre-poured medications to Resident #3. Based upon observation, the facility failed to ensure that medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Plan of Correction:	1. Employee was retrained on 5/10/2023 by Director of Nursing (DON) in ensuring that medications shall remain in the pharmacy issued container until administered to the resident. 2. DON or designee will provide an in-service to all current licensed practical nurse and medication aides by 6/8/2023 that medications shall be removed from the pharmacy packaging and administered immediately (pre-pouring is not permitted) by the same authorized person. A medication pass review will be completed for each person passing medications (licensed nurse/medication aide) by 6/8/2023. 3. Administrator, DON, or designee will observe at least one medication pass monthly. 4. DON or designee will monitor weekly x4 weeks then monthly. All findings will be addressed immediately and reviewed/reported during next scheduled Quality Assurance meeting.
Standard #:	22VAC40-73-680-H
Description:	Based upon a review of records and observation, the facility failed to ensure that at the time medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements. Evidence: 1. On 5/8/2023 at approximately 10:05 am, LI observed Staff #5 administer the following medications to Resident #3: a. Eliquis b. Escitalopram c. Furosemide d. Valacyclovir HCl e. Hydrocod/APAP 2. On 5/8/2023 LI reviewed the May 2023 medication administration record (MAR). According to the May 2023 MAR, Staff #5 failed to document the medications administered to Resident #3 at approximately 10:05 am on 5/8/2023.
Plan of Correction:	1. Employee was retrained on 5/10/2023 by Director of Nursing (DON) on medication administration record (MAR) documentation. 2. DON held an in-service training with current charge nurses and medication aides on the MAR documentation. Pharmacy will provide an in-service training on med pass for the licensed practical nurses and medication aides by 6/20/2023. 3. Administrator, DON, or designee will review resident MAR records weekly. A medication pass review will be completed for each person passing medications (licensed practical nurses and medication aides) by 6/8/2023. 4. DON or designee will monitor by conducting random MAR record audits weekly x4 weeks and then monthly. All findings will be addressed immediately and reviewed/ reported during the next scheduled QA meeting.
Standard #:	22VAC40-90-60-C
Description:	Based upon a review of records, the facility failed to make available to the licensing representative criminal history record reports. Evidence: 1. During a review of criminal history record reports by LI on 5/8/2023,the facility could not make available the criminal history record reports for the following staff members: #18, #19, #20, #21, #22, #23, #24, #25, and #26.
Plan of Correction:	1. A criminal background check was completed on the following staff: #18, #19, #20, #21, #22, #23, #24,#25, and #26 on 5/8/2023. 2. Business Office Manager (BOM) or designee reviewed all active employees files as of 5/8/2023 to ensure current employees have a criminal background check on file. 3. BOM completed a review of all current employees files as of 5/8/2023. Administrator held an in-service with BOM regarding said regulatory standard and compliance. 4. Quality Assurance (QA) meeting was held on 5/18/2023 with Administrative team. Executive Director will monitor compliance by conducting random audits of newly hired employee files weekly x4 weeks and then monthly thereafter. All findings will be addressed immediately and reviewed/reported during the next scheduled QA meeting.