VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Chestnut Grove Assisted Living Facility
9010 Woodman Road
Richmond, VA 23228
(804) 262-7333

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Feb. 7, 2024

Complaint Related: Yes

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: On 01/26/2024 Approximate time 11 :51 a.m-2:03p.m.; 01/30/2024 Approximate time 12: 35p.m-1 :09p.m.; 02/07/2024 Approximate time 12: 03 .m-2:18 .m The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VOSS Division of Licensing on 12/20/2023 regarding allegations in the areas of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 68 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: The resident identified in the complaint is no longer in care. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the (allegation(s)/self-report); area(s) of noncompliance with standard(s) or law were: resident care and related services A violation notice was issued; any violation(s) not related to the (complaint(s)/self-report) but identified during the course of the investigation can also be found on the violation notice. 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 on compliance 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 VOSS Licensing Programs, please visit: www.dss.virqinia.gov Should you have any questions, please contact Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves @dss.viginia. gov. Violation Notice yes

Violations:

Standard #:	22VAC40-73-460-F
Complaint related:	No
Description:	Based on the review of facility records and staff interviews conducted, the facility failed to notify the next of kin, legal representative, designated contact person, of a resident incident. Evidence: Interviews conducted and the review of facility documentation did not reveal that the facility notified the resident?s legal representative regarding the resident?s 02/11/2023 injury that required outside medical emergency intervention. Facility staff stated that the resident?s hospice representative made notification to the resident?s legal representative.
Plan of Correction:	FACILITY'S RESPONSE " The Administrator, Resident Services Coordinator and or designee will ensure the facility notifies the next of kin, legal representative or designated contact person of any incident involving a resident as soon as possible and no later than 24 hours from the time of initial discovery or knowledge of the incident. In-Service to educate staff on proper incident reporting procedures held on 2/13/2024."