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: Sept. 18, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 09/18/2024 9:35AM to 11:30AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 08/05/2024 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 107 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: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-130-A
Description:	Based on documentation review and staff interview, all staff who are mandated reporters under 63.2-1606 of the Code of Virginia shall report suspected abuse, neglect, or exploitation of residents in accordance with that section. EVIDENCE: 1. The licensing inspector (LI) received an incident report on 08/05/2024 from staff person 1 that there was a resident-to-resident altercation between residents 1 and 2 on 08/04/2024 and resident 1 obtained a small skin tear to his right arm from resident 2 during the altercation. 2. During on-site inspection on 09/18/2024, staff person 1 informed the LI that this incident had not been reported by the facility to their local Adult Protective Services Agency as required by 63.2-1606 of the Code of Virginia.
Plan of Correction:	Immediate Corrective Actions - The Executive Director will include in their reports any resident-to-resident altercations to both APS and DSS starting 9/18/24. Additional Corrective Actions - The Executive Director will include the Regional Executive Director of Operations in all correspondence to the governing authorities (DSS, APS, etc) to ensure all parties have been contacted according to the regulatory guidelines. Ongoing Quality Assurance Actions - The Executive Director or Resident Care Director will review a sample of reportables each month as part of the Quarterly Quality Assurance process. Findings will be reviewed at the Quarterly Quality Assurance Meeting to ensure compliance and review any concerns or trends. This will begin with the Quarterly Meeting in October 2024, scheduled to review the third quarter documentation.