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: March 15, 2021 and March 17, 2021

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 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. 22VAC40-80 THE LICENSING PROCESS.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 3/15/2021 and concluded on 3/17/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 87. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed five resident records, five staff records, staff work schedule, dietary and healthcare oversight reports, fire drill reports, and annual health and fire inspections, submitted by the facility to ensure compliance. LI completed the entrance and exit interview with the administrator. LI reviewed the Criminal Background Checks for all staff hired since the last mandated inspection conducted on 2/25/2020. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility. LI completed the exit interview with the administrator via telephone on 3/17/2021. During the exit interview LI reviewed the violations with the administrator. 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 #:	22VAC40-73-260-A
Description:	Based upon a review of records and interview with administration, the facility failed to ensure that each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment . Evidence: Neither Staff #3 (date of hire 11/19/2020) nor Staff #4 ( date of hire 9/29/2020) had verifications of current First Aid Certification in their records.
Plan of Correction:	A direct care file audit will be immediately conducted to ensure all direct care staff members have First Aid Training. Newly hired employees, who are not First Aid certified will be registered for First Aid training within their first 60 days of employment by the community's Executive Director (ED) or designee. Quarterly audits of direct care staff records will be conducted by the ED or designee to ensure continued compliance.