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: April 29, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

640A, 325C

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 04/29/2020 and concluded on 05/14/2020. A self-reported incident was received by the department regarding allegations in the areas of resident care. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-325-B
Description:	Based on resident record review and staff interviews, the facility failed to ensure that the fall risk rating was reviewed and updated after a fall. EVIDENCE: 1. Documentation for resident 1 showed that resident 1 had falls on 12/27/2019, 02/01/2020 and 04/07/2020. 2. Phone interview with staff 1 and staff 2 on 04/30/2020 revealed that the IDENTIFICATION OF RISKS assessment is used as the facility?s fall risk assessment. 3. IDENTIFICATION OF RISKS assessment was completed on 04/11/2020 after the fall on 04/07/2020. However, there was no IDENTIFICATION OF RISKS assessment after the falls on 02/01/2020 and 12/27/2019.
Plan of Correction:	What: Resident had documented falls on 12/27/2019, 2/1/2020 and 4/7/2020. Identification of risk assessment was completed for the 4/7/2020 fall on 4/11/2020 as well as completed on 11/21/2019 when resident changed condition and moved to memory care. However, a falls risk rating was completed and documented on the incident reports for the falls on 12/27/2019, 2/1/2020 and not on the Identification of Risk form. A falls risk rating was also completed and documented on the incident report for the fall on 4/7/2020. How: An updated Identification of Risk form will be completed by the Resident Care Director or designee as part of the falls risk rating, with each fall. (See Exhibit A: Heritage Green falls management program forms including Identification of Risk form and other falls evaluation tools.) Ongoing: Executive Director or designee will proactively review the Identification of Risk ratings on an ongoing basis and will be reviewed at the Quarterly Quality Assurance Meeting.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to include all identified needs on the comprehensive individualized service plan (ISP). EVIDENCE: 1. On 12/27/2019 staff 2 assessed resident 1 as fall risk level ? high. The ISP for resident 1 dated 04/11/2020 did not include that resident 1 is a high fall risk, nor did it include interventions/supports to prevent falls.
Plan of Correction:	What: Resident?s updated ISP on 4/11/2020 did not include her fall risk or interventions / supports to minimize risk of falls. Identification of Risk form was completed on 4/11/2020. Other community falls evaluation tools were also completed on 4/11/2020 and reviewed and signed by POA on 4/17/2020. How: Resident?s ISP was corrected 5/1/2020 to reflect the falls risk rating, assessment, interventions / support to minimize risk of falls. (See Exhibit A.) Ongoing: Resident Care Director, Memory Care Director or designee will ensure all resident?s ISP reflects the falls risk, assessment, and interventions / support to minimize risk of falls.