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: Oct. 28, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Comments:

A renewal inspection was initiated on 10/26/2021 and concluded on 10/29/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 95. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 5 resident records, 5 staff records, activities calendar, menu, staff schedule, recent health care oversight, recent health department and fire inspections, dates of the past year's fire drills, recent dietitian review, and sworn disclosures and criminal record checks for staff hired and still employed since the facility's last mandated inspection submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 10/28/2021. An exit interview was conducted with the Administrator and the Resident Care Director on 10/28/2021, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. The Administrator and the licensing inspector had a discussion regarding standard 870-A. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-610-B
Description:	Based on observation, the facility failed to ensure that menus for meals for the current week were dated and posted in an area conspicuous to residents. EVIDENCE: 1. During on-site inspection on 10/28/2021, the menu posted in the memory care building of the facility was not for the current week.
Plan of Correction:	How: The correct menu was re-posted on the day of inspection. Ongoing: The Dietary Manager or designee will review the dietary board daily to ensure the correct menu is posted. The ED will randomly check the menu boards during rounds to ensure the correct menu is posted. The Dietary Manager will audit monthly QA and review at the quarterly QA meeting.
Standard #:	22VAC40-73-640-A
Description:	Based on document review, the facility failed to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The facility?s current medication management plan, ?Heritage Green Assisted Living Communities Medication Management Plan? states ?Narcotics are double locked and counted by two med staff persons at the beginning and end of each shift. If an RMA has worked a double shift, they still need to count per the policy at the end of the change of shift time.? 2. The two medication carts in the assisted living building of the facility contained ?Controlled Drug Count Record? logs for September and October 2021 for a total of four controlled drug count records. There were multiple shifts that did not contain the signature of the medication staff that was coming on shift and/or going off shift for the September and October 2021 controlled drug count record logs.
Plan of Correction:	How: RMA training was conducted on 11/4/21 to review completing the Controlled Drug Count Record at the beginning and end of the shift during narcotic counting. Ongoing: RCD or designee will randomly observe shift count. The Controlled Drug Count Record will be checked daily for accuracy and will be reviewed monthly with QA task and during the quarterly QA meeting.
Standard #:	22VAC40-73-650-A
Description:	Based on resident record review and staff interview, the facility failed to obtain a valid order from a physician or other prescriber prior to changing the way medication is administered to residents. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 4, dated 08/12/2021, stated that ? RMA, LPN resident takes medications crushed in applesauce PRN? and the individualized service plan (ISP), dated 08/12/2021, stated that ?may crush all crushable medications?. The UAI for resident 5, dated 07/08/2021, stated that ?RMA/LPN?. Resident takes med crushed in applesauce? and the ISP, dated 07/08/2021, stated that ?medications will be crushed and placed in applesauce as needed?. Interview with staff 7 revealed that she does administer medications to residents 4 and 5 in applesauce. The records for residents 4 and 5 do not contain a valid order from a physician or other prescriber that the medications for these two residents may be crushed and/or administered with applesauce.
Plan of Correction:	How: All resident records have been audited by the MCD and RCD to ensure the MD orders are present for residents that require crushed meds with the addition of "may place in applesauce or pudding". Ongoing: Monthly audits will be completed by RCD and MCD or designee to ensure crushed med MD orders include all components including applesauce or pudding (if applicable). RCD and MCD or designee will monitor monthly QA and review quarterly at the QA meeting.
Standard #:	22VAC40-73-660-B
Description:	Based on observation from tour of the facility, resident record review and staff interview, the facility failed to ensure that for a resident that had his own medication in his room the uniform assessment instrument (UAI) indicated the resident is capable of self-administering medication. EVIDENCE: 1. During on-site inspection on 10/28/2021, the licensing inspector observed a bottle of Alka-Seltzer heartburn and gas relief tabs on the table beside the resident?s recliner in the living room in resident 6?s room. Resident 6 revealed that she takes these tablets on her own. 2. The UAI for resident 6, dated 10/04/2021, indicates that medication is administered to the resident by ?RMA (registered medication aide)/NURSE?. Interview with staff 6 confirmed that the resident?s medications are administered by facility medication staff.
Plan of Correction:	How: Reviewed resident?s medications with Nurse Practitioner due to increased heartburn. Medication adjustments made to decrease the need for heartburn relief. Resident is in agreement with change. RMAs will offer as needed medications as ordered by MD in the event of distress. Ongoing: Room sweeps will be completed weekly by RCD or designee for any medications at bedside without the MD order for self-administration. RCD will audit monthly QA and review at the quarterly QA meeting.
Standard #:	22VAC40-73-680-M
Description:	Based on resident record review, observation, and staff interview, the facility failed to ensure medications orders for PRN (as needed) administration were available. EVIDENCE: 1. The record for resident 5 contained a signed physician?s order, dated 10/26/2021, for ?Quetiapine Fumarate 25MG tab take ? tablet by mouth every 6 hours as needed DX: restlessness and agitation?. This medication was not observed in the medication cart during the medication cart/storage audit on 10/28/2021. Staff 6 confirmed that the aforementioned PRN medication was not onsite and available.
Plan of Correction:	How: MCD and RCD obtained a MD order to discontinue Seroquel as needed due to non-usage. All as needed medications were reviewed and updated MD orders to discontinue non-used as needed medications over 60 days. Ongoing: RCD and MCD or designee will audit medications and med carts weekly to ensure all current ordered medications are available in the facility. RCD and MCD audit monthly QA and will review at the quarterly QA meeting.
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review, the facility failed to ensure a valid physician?s order for oxygen contained all the required components. EVIDENCE: 1. The record for resident 1 contained a physician?s order, dated 10/26/2021, that showed ?Oxygen as needed O2@2 LPM for shortness of breath/dyspnea?. The order does not contain the oxygen source or the delivery device.
Plan of Correction:	How: RCD and MCD obtained clarification from Hospice provider/nurse for oxygen order to include route and delivery source. Ongoing: RCD and MCD reviewed all oxygen orders to ensure each component of the order is present. Alerted all hospice providers to include all components in each oxygen order. RCD and MCD will monitor all new oxygen orders for completion of all components and add to ISP. RCD and MCD will audit monthly QA and will review at the quarterly QA meeting.
Standard #:	22VAC40-90-30-B
Description:	Based on staff record review, the facility failed to ensure that the sworn statement or affirmation was completed for all applicants for employment. EVIDENCE: 1. The record for staff 9, date of hire 05/11/2021, contained documentation that the sworn statement or affirmation was completed after the date of hire on 05/12/2021. The record for staff 10, date of hire 06/09/2021, contained documentation that the sworn statement or affirmation was completed after the date of hire on 06/11/2021.
Plan of Correction:	How: BOM or designee will ensure any new staff member will complete a written Sworn disclosure upon the date of hire. Ongoing: ED or designee will audit all new employee charts monthly to ensure all components of the hiring process have been completed. The BOM will audit monthly QA and will review at the quarterly QA meeting.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review and staff interview, the facility failed to ensure that a criminal history record report was obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The record for staff 8, date of hire 09/08/2021, contained documentation that a criminal record history report was not obtained until 10/26/2021. Interview with staff 6 confirmed this was accurate.
Plan of Correction:	How: An audit was completed by BOM and designee of all staff member?s charts. All new hire charts will be audited by ED or designee on the 30th day. BOM or designee will follow up with Virginia State Police on the 30th day of hire for retrieval of the criminal background check. If the criminal background check has not been obtained within the 30 days of hire, the staff member will be removed from the schedule. Ongoing: Monthly audits will be performed by the ED or designee and all audits will be reviewed at the quarterly QA meeting.
Standard #:	22VAC40-90-40-D
Description:	Based on staff record review and document review, the licensee failed to ensure that an employee has not been convicted of any of the barrier crimes when a criminal history record was requested. EVIDENCE: 1. The document ?Barrier Crimes for Licensed Assisted Living Facilities and Adult Day Care Programs?, dated August 2021, states that an assisted living facility cannot hire anyone who has a conviction for an offense in clause (i) of the barrier crime definition in 19.2-392.02 of the code and ?barrier crime? under Code 19.2-392.02, Clause (i) includes any felony violation of any of the offenses listed on the six page document. 2. The record for staff 11, date of hire 01/04/2021, contained a Virginia criminal record, dated 01/05/2021, that staff 11 was found guilty of a felony barrier crime that is listed on the document ?Barrier Crimes for Licensed Assisted Living Facilities and Adult Day Care Programs?. During the inspection, staff 11 was still employed at the facility.
Plan of Correction:	How: BOM or designee will complete audits on all employees charts to ensure compliance of not employing any staff members with barrier crimes. Ongoing: All criminal backgrounds will be reviewed by ED for any barrier crime(s) on or before the 30th day. If any noted, the ED or designee will discharge the employee due to ineligibility of employment. BOM or designee will monitor during monthly QA and review during the quarterly QA meeting