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: April 25, 2024

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

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/25/2024 Begin: 8:49am End: 2:10pm 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: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: 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 Crystal B .Henson, Licensing Inspector at276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-C-1
Description:	Based on an audit of the Terrace medication cart, the facility failed to implement and follow their infection control plan. EVIDENCE: 1. Per the facility?s Blood Glucose Monitoring policy, last revised Nov 29, 2023, #3 states, ??.the meter will be labeled for the specific resident and stored in a bag labeled with the resident?s name. 2. LI observed an unlabeled glucometer in a labeled bag. The bag holding the glucometer had resident #7?s first initial and last name along with his/her room number indicated on the bag
Plan of Correction:	The sanitation of equipment, including medical equipment that may be used on more than one resident (e.g., blood glucose meters and blood pressure cuffs, including cleaning and disinfecting procedures, agents, and schedules) Corrective Action: Medication Aide was retrained on 4/26 by DON on labeling blood glucose meter and bag. How to identify other staff/residents: DON held an in-service training with current charge nurses and medication aides on labeling blood glucose meter and bag. Systemic Changes: Administrator, Director of Nursing or designee will audit medication cart to ensure proper labeling compliance of medical equipment. A medication cart audit will be completed for each person passing medications (licensed nurses and medication aides) by 6/9. Monitoring Process: Will monitor by conducting random audits by DON or Administrator weekly x4 weeks then monthly. All findings will be addressed immediately and reviewed/reported) during the next scheduled QA meeting. [sic]
Standard #:	22VAC40-73-210-D
Description:	Based on staff record review and staff interview, the facility failed to ensure training for a medication aide was completed as required by the Virginia Board of Nursing. EVIDENCE: 1. Staff #1 was hired on 7/25/2011, staff #1?s file contained documentation of the Registered Medication Aide (RMA) 4 Hour Refresher Training completed on 8/23/2021 however there was no documentation for the years of 2022 and 2023. 2. During an interview with two licensing inspectors and Staff #4 on 4/25/2024, staff #4 confirmed there were no training certificates available in the facility filed for the years 2022 and 2023 for staff #?s record for the RMA 4 hour Refresher Training.
Plan of Correction:	In addition to the training curriculum, the program may provide one or more four-hour modules that can be used by facilities as refresher courses or by medication aides to satisfy requirements for continuing education. Corrective Action: Office Manager and DON was retrained on 4/26 by administrator on continuing education for medication aides. How to identify other staff/residents: An audit was conducted by the Office Manager of the medication aides as of 4/25. A medication refresher course is scheduled for May 15th and May 22nd . Systemic Changes: Administrator, Director of Nursing or designee will review the medication aide files annually. Monitoring Process: Administrator or designee will audit staff records weekly x4 weeks then monthly by Office Manager or designee to continue education compliance. All findings will be addressed immediately and reviewed during the next scheduled QA meeting. [sic]
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to obtain the criminal history report on or prior to the 30th day of employment for six employees EVIDENCE: 1. Staff #10 was hired on 11/24/2023; a criminal history report was not obtained until 03/09/2024. 2. Staff #11 was hired on 10/10/2024; a criminal history report was not obtained until 03/09/2024. 3. Staff #12 was hired on 11/20/2023; a criminal history report was not obtained until 03/09/2024. 4. Staff #15 was hired on 09/28/2023; a criminal history report was not obtained until 03/09/2024. 5. Staff #17 was hired on 10/20/2023; a criminal history report was not obtained until 03/11/2024. 6. Staff #18 was hired on 11/10/2023; a criminal history report was not obtained until 03/11/2024. .
Plan of Correction:	Corrective Action: Employee was retrained on 04/26 by Administrator on timeliness of criminal background check. How to identify other staff/residents: BOM or designee reviewed all active employees? files as of 4/25 to ensure current employees have a criminal background check that are within 30 days of hire on file. Systemic Changes: BOM completed a review of all current employee files as of 4/25. Administrator held an in-service with BOM regarding said regulatory standard and compliance. Monitoring Process: QA meeting was held with administrative team to ensure criminal background check of new hire are in compliance with mandatory standards. Newly hired employee files weekly x 4 weeks then monthly thereafter. All findings will be addressed immediately and reviewed/reported during the next scheduled QA meeting. [sic]