VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Heritage Green Assisted Living Communities
201 & 202 Lillian Lane
Lynchburg, VA 24502
(434) 385-5102

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Feb. 24, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION.

Comments:

The LI for Heritage Green Assisted Living in conjunction with another LI conducted an unannounced complaint investigation in response to a complaint that was received by the licensing office on 02/12/2020. The LIs reviewed one resident record, one staff record and conducted staff interviews relating to an allegation of staff roughly handling a resident. The information gathered during the investigation supports the allegation. Based on the preponderance of evidence the complaint is determined to be valid. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to your licensing inspector 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, contact your licensing inspector at (540) 589-5216.

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on staff interviews, the facility failed to ensure 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. The record for staff 3 contained an incident report dated 02/05/2020, this report showed "resident (1) stated that a staff member treated her roughly. She stated she was able to transfer self. Staff (3) wouldn't give her that opportunity and grab her arm and slung her in the bed. Bruise noted to left arm." The facility failed to report this incident to the department of licensing programs. The record shows that staff 3 was terminated following this incident.
Plan of Correction:	All staff will be retrained on Mandatory Reporting of Abuse, Neglect and Exploitation. This training will review timeliness of reporting guidelines. Monthly QA audits of all incidents will be completed and reviewed at the Quarterly QA meetings.
Standard #:	22VAC40-73-450-B
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that resident's comprehensive individualized service plan (ISP) was designed to maximize the resident's level of functional ability. EVIDENCE: 1. The ISP dated 11/07/2019 stated the description of needs and services to be provided for resident 1 are as follows: transfer resident with 1:1 physical assistance by care assistants ailed at the facility. 2. Interview with staff 2 revealed that resident 1 needs assistance some days with transferring and some days she does not but likes to have someone close by when transferring. 3. The record for staff 3 contained written statement dated 02/06/2020 signed by staff 2 and resident 1 "(resident 1) stated that the Aid (staff 3) that had her was so rough with her. She wasn't listening to her. She request that she let her do it herself put herself in the bed. She stated (staff 2) I know I am slow but I could have done it. Instead of letting me do it she grab my and slung me in the bed. She showed recorder (staff 2) and sitter a bruise to L arm. She request that she not return to her room."
Plan of Correction:	ISP on 11/7/2019 states that resident is to be transferred by 1:1 physical assistance by care staff. The ISP reflects the higher level required by the resident, the physical assistance she often requires. Resident Care Director has updated the ISP to reflect that the resident at times, prefers supervision assistance over physical assistance, and staff will offer what the resident prefers at that time. RCD has informed staff of this change to the ISP in via the communication log. Monthly QA audits will be completed and reviewed at the quarterly QA meeting to ensure ISP?s are reflective of resident needs.
Standard #:	22VAC40-73-550-C
Complaint related:	No
Description:	Based on record review, the facility failed to ensure that a resident of an assisted living facil- ity had the right and responsibilities ? 63.2-1808 of the code of Virginia . EVIDENCE: 1. The record for staff 3 contained an EMPLOYEE CORRECTIVE ACTION REPORT dated 02/10/2020 . This report stated "following investigation of complaint from resident (resident 1) on 02/06/2020 of potential physical abuse, it was determined that (staff 3) handled the resident in a rough manner, resulting in a bruise visible on resident's (resident 1) wrist. For this (staff 3) is being terminated".
Plan of Correction:	Staff 3, All staff to include new hires will be re-trained and all new hires are trained on abuse, neglect, and exploitation policies as well as mandated reporter policies. Staff 3 was terminated as a result of the facility?s internal investigation of the resident?s complaint of abuse. Facility conducts criminal background checks on all staff per DSS regulations. Facility will continue to carry out measures to help ensure residents are protected from abuse, neglect, and exploitation.