Virginia DSS · Assisted Living Facility

Chestnut Grove Assisted Living Facility

📍 9010 Woodman Road, Richmond, VA, 23228

ID 33857Two Year licenseActive
13
Inspections
On record
5
With violations
Visits that cited something
8
Clean visits
Nothing cited
8
Violations cited
Individual findings
7
Standards cited
Distinct rules
7
Complaint visits
Prompted by a complaint

Chestnut Grove Assisted Living Facility was inspected 13 times between July 22, 2020 and May 27, 2026 by the Virginia Department of Social Services. 5 of those visits ended with violations cited and 8 with none. Across that history VDSS cited 8 violations under 7 distinct standards. 7 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 10 of these 13 are still on the state's site; the other 3 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
06/18/2028
Administrator
Lenny Wilkinson
Licensing inspector
Tyia Venable
Inspector phone
(804) 393-2157
Approved for
Special Care Unit · Assisted Living · Non-Ambulatory

Inspection History

13

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

May 27, 2026Inspection0 violations
Inspection dates
05/27/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
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: 5/27/2026, 12:30pm-3:26pm 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: 67 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector observed required facility postings, medication pass, lunch, and afternoon activity. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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 Tyia Venable, Licensing Inspector at 804-393-2157 or by email at tyia.venable2@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 9, 2025Complaint survey0 violations
Inspection dates
07/09/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION
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: 7/9/2025, 11:16am-12:25pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 4/14/2025 regarding allegations in the area(s) of: staffing and supervision Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector reviewed facility staffing schedule. Additional Comments/Discussion: Incident reports for the months of April 2025 were reviewed during the inspection. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Tyia Venable, Licensing Inspector at (804)393-2192 or by email at Tyia.Venable2@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 24, 2025Inspection1 violation
Inspection dates
01/24/2025
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: On 01/24/2025 approximate time 10:00-2:21p.m On 02/24/2025 approximate time 9:28a.m-10:46p.m 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: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 7 Observations by licensing inspector: An afternoon medication administration pass. 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov. Violation Notice Issued: Yes
Violations
22VAC40-73-70-A
Based on the review of facility records and staff interviews the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. Resident # 1 The facility did not report that on 01/15/2025 the resident had a fall and was sent to the emergency room. Resident returned same day.
Plan of correction
THE FACILITY'S RESPONSE: "The Administrator and or designee will ensure that the facility reports to the regional licensing office of any major incident that has affected or that threatens the life, health or safety or welfare of any resident within 24 hours of the incident."
December 9, 2024Complaint survey2 violations
Inspection dates
12/09/2024, 01/24/2025, 02/24/2025
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: 12/09/2024Approximate time 10:29a.m-4:13p.m. On 01/24/2025 Approximate time -2:13p.m. On 02/24/2024 Approximate time 9:38-10:46A.m The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/21/2025 regarding allegations in the areas of Personnel. Staffing and Supervision, Resident Care and Related Services, Resident Accommodations and Related Services, Regulations for facilities that care for adults with Serious Cognitive Impairments Number of residents present at the facility at the beginning of the inspection: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: N/A Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Staff and resident interaction revealed no concerns Additional Comments/Discussion An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the area(s) of non-compliance with standard(s) or law Personnel. Staffing and Supervision, Resident Care and Related Services, Resident Accommodations and Related Services, Regulations for facilities that care for adults with Serious Cognitive Impairments A violation notice was issued; any violation(s) not related to the complaint 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 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov. Violation Notice Issued: Yes
Violations
22VAC40-73-70-A
Based on the review of facility records and staff interviews the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. Resident #s 1, 2The facility did not report the 10/13/2024 resident to resident physical altercation between resident #s 1 and 2 as required. Resident #1 was injured in the altercation.
Plan of correction
THE FACILITY'S RESPONSE: "The Administrator and or designee will ensure that the facility reports to the regional licensing office of any major incident that has affected or that threatens the life, health or safety or welfare of any resident within 24 hours of the incident."
22VAC40-73-130-A
Based on the review of facility records and staff interviews the facility failed to report under § 63.2-1606 of the Code of Virginia suspected abuse ,neglect, or exploitation of residents in accordance with that section.
Evidence
  1. Resident #s 1, 2The review of facility records and staff interviews revealed that resident #2 physically injured resident #1 on 10/13/2024 and that the facility did not report the incident to the Adult Protective Services agency.
Plan of correction
Not published by VDSS.
December 9, 2024Complaint survey0 violations
Inspection dates
12/09/2024, 01/24/2025
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: On12/09/2024 Approximate time 10:29a.m-4:13p.m. On 01/24/2025 Approximate time 11:29a.m -2:31p.m. On 02/24/2025Approximate time 9:28a.m-10: 46a.m The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/21/2024 and 11/20/2024 regarding allegations in the areas of Personnel, Staffing and Supervision, Resident Care and Relates Services, Resident Accommodations and Related Provisions and Additional Requirements for Facilities That Care for Adults With a Serious Cognitive Impairment. Number of residents present at the facility at the beginning of the inspection: 64 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: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Resident and staff interaction revealed no concerns. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Angela Rodgers-Reaves Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: No
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 8, 2024Complaint survey0 violations
Inspection dates
07/08/2024
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: 07/08/2024 approximate time 10:52-12:21 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 07/05/2024 regarding allegations in the areas of resident care and related services, resident accommodations and related provisions and building and grounds. Number of residents present at the facility at the beginning of the inspection: 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: 1 Number of interviews conducted with staff: N/A Observations by licensing inspector: The resident’s room was observed by the inspector. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: No
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 18, 2024Inspection1 violation
Inspection dates
04/18,19/2024
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: On 04/18/2024 approximate time 10:15-12:25p.m On 04/19/2024 approximate time 11:54a.m-2:38P.m. 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: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: An afternoon medication administration pass was observed on 04/19/2024 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov
Violations
22VAC40-73-970-A
Based on the review of facility records and interview with the Administrator the facility failed to ensure that the fire and emergency evacuation drills are conducted in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month.
Evidence
  1. Facility documentation reviewed with the Administrator revealed that no fire drill was conducted for the month of March 2024
Plan of correction
THE FACILITY'S RESPONSE: " The Administrator, Maintenance Director, and or designee will ensure that the facility conducts the fire and emergency evacuation drills monthly and will be conducted in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills will be conducted monthly and will cover each shift in a quarter."
February 7, 2024Complaint survey0 violations
Inspection dates
02/07/2024
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 02/07/2024 Approximate time 12:03p.m-2:18p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 02/02/2024 regarding allegations in the resident care and related services and requirements for adults with serious cognitive impairments. 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: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: The facility courtyard is enclosed and locked. Resident not in danger or has ability of eloping from the property. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov. Violation Notice Issued: No
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 7, 2024Complaint survey1 violation
Inspection dates
01/26, 30/2024 02/07/2024
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
22VAC40-73-460-F
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
  1. 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."
June 5, 2023Inspection0 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 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: 6/5/2023 11:00 a.m.-3:00 p.m. 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: 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: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Activities, lunch meal, physician’s orders, medication administration pass, medications, water temperature, all required postings, emergency supplies, food, water and first aid kit, criminal background checks on all new hires since last inspection. Additional Comments/Discussion: Staff members were given the opportunity to ask questions. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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 Belinda Dyson for Angela Rodgers-Reaves, Licensing Inspector at (804) 662-9780 or by email at belinda.dyson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 6, 2022Inspection0 violations
Comments
The inspector was onsite at the facility on 06/06/2022 between the approximate times of 10:20a.m and 2:15p.m. The facility Administrator offered 75 residents in care. Upon arrival to the facility some residents were preparing for an outside activity. Based on the census offered the inspector reviewed four residents records, four staff records as well as other facility documentation to determine compliance. Accompanied by the facility Administrator a tour of the facility’s physical plant was conducted and required posting were noted. Throughout the inspection interviews were conducted with residents and staff. A mid-day medication pass was observed. There were no obvious concerns noted regarding the medication cart. An exit interview was conducted with the facility Administrator on 06/06/2022. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at angela.r.reaves@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 26, 2021Inspection0 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
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 04/26/2021 and concluded on 05/31/2021. The licensing inspector emailed the administrator a list of documentation required to complete the inspection. The evidence gathered during the inspection determined compliance with applicable standards or laws. The facility Administrator reported that the current census was 64. The inspector reviewed four resident records, four staff records, and other facility documentation such as staff schedules, annual review of residents? rights, staff training, pharmacy review, medication administration records, facility policy etc. submitted by the facility to ensure documentation was complete. A virtual tour of the physical plant was conducted on 05/13/2021. 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
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 22, 2020Complaint survey3 violations
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
22VAC40-73-440-A
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
  1. 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"
22VAC40-73-450-F
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
  1. Resident #1-Documented date of admission 07/29/2019 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."
22VAC40-73-460-D
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
  1. 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. "