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: July 22, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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. Responding to allegations made against the facility a complaint investigation was initiated on 07/22/2020 and concluded on 06/07/2021. The licensing inspector emailed the administrator a list of documents required to complete the investigation. The evidence gathered during the investigation supported the determined non-compliance(s) with applicable standards or law. Violations were documented and are on the violation notice issued to the facility. The inspector conducted interviews with facility staff and others and reviewed facility records. The facility was offered technical assistance regarding the noncompliance that was cited. Based on the data collected the complaint is valid. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and returned it to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions please feel free to contact me at (804)662-9774 or by e-mail at Angela.r.reaves@dss.virginia.gov if you have any questions.

Violations:

Standard #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on the review of facility records and interviews with the facility Administrator the facility failed to ensure that the UAI was updated whenever there is a significant change in the resident's condition. Evidence: Resident #1 Documented date of admission: 07/29/2019 Facility records submitted for the inspector?s review also notes that prior to admission the facility assessed the resident on 07/24/2019 as needing no assistance with her activities of daily living (ADLs); bathing, dressing, toileting, transferring and eating. Facility records submitted for the inspector?s review also revealed that beginning 05/10/2020 until 06/15/2020 facility staff documented that the resident was being provided assistance with her daily ADL care that included feeding the resident and assisting the resident with toileting and transferring. The facility did not reassess the resident based on the change in her level of care.
Plan of Correction:	FACILITY RESPONSE: "The Resident Services Coordinator, Administrator, and or Designee will continue to review for potential changes of resident AOL Care. The Resident Services Coordinator, Administrator, and or Designee will conduct Oversight Reviews to ensure compliance. Date corrected: June 25, 2021"
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on the review of facility records and interviews with the facility Administrator the facility failed to ensure that the Individualized service plans was updated at least once every 12 months and as needed as the condition of the resident changes. The review and update shall be performed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons. Evidence: Resident #1-Documented date of admission 07/29/2019 Facility records revealed that at the time that resident #1 was admitted to the facility, the resident was independent with her activities of daily living (ADLs) and scored to be a low risk for falls. Beginning 05/15/2020 facility staff documented on the 24 Hour Report that the resident was being provided assistance with toileting and transferring. A 05/19/2020 document from a local specialized physician that the facility submitted for the inspector?s review notes in part that the resident ?is at an increased risk of fractures given her age and thinning bones.? Facility records submitted for the inspector?s review also noted multiple falls the resident had while in care at the facility but the resident?s 07/24/2019 ISP was not updated to identify a plan to address the resident?s change in level of care or a plan to address fall prevention.
Plan of Correction:	FACILITY RESPONSE: "The Resident Services Coordinator, Administrator, and or Designee will continue to update the Individualized Service Plan at least every 12 Months and as needed as the condition of the resident changes. The Resident Services Coordinator, Administrator, and or Designee will conduct Oversight Reviews to ensure compliance."
Standard #:	22VAC40-73-460-D
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs. Evidence: Resident #1-Documented date of admission 07/29/2019 Facility records submitted for the inspector?s review revealed staff?s knowledge that resident #1 was admitted to the facility needing no assistance with her activities of daily living (ADLs). Facility documentation and documentation the facility submitted for the inspector?s review regarding the resident?s assessment from a local specialist noted the resident?s multiple falls and the resident?s decline from being independent to now needing assistance with her daily ADL care. The neuro-specialist?s 05/19/2020 report notes in part that the resident had multiple falls over the last several months with fracture in her neck. The facility assessed the resident beginning 05/10/2020 as being a high fall risk-scoring 80 points; but the facility did not submit a documented plan of care for facility direct care staff to implement that provided guidance for implementing a structured plan of care that identified preventative measures with reducing the falls.
Plan of Correction:	FACILITY RESPONSE: "The Resident Services Coordinator, Administrator, and or Designee will continue to provide supervision of Resident Schedules, care, and Activities, including attention to specialized needs, such as prevention of falls. The facility will document fall prevention measures in the residents plan of care. The Resident Services Coordinator, Administrator, and or Designee will conduct Oversight Reviews to ensure compliance. "