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. 21, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-80 COMPLAINT INVESTIGATION

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: 10/21/2024 8:57AM to 10:20AM 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 10/10/2024 regarding allegations in the areas of: personnel & resident care and related services Number of residents present at the facility at the beginning of the inspection: 106 Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-190-C
Complaint related:	No
Description:	Based on staff record review and staff interview, the facility failed to ensure prior to being placed in charge, the staff member shall be informed of an receive training on his duties and responsibilities and provided written documentation of such duties and responsibilities. EVIDENCE: 1. Interview with staff person 3 on 10/21/2024 revealed that staff person 1 was in charge on 10/06/2024. 2. The job descriptions in the record for staff person 1, dated 04/02/2021, do not include information of staff person 1?s duties and responsibilities when they are the person in charge. Staff person 3 confirmed this is accurate.
Plan of Correction:	Immediate Corrective Actions: The job description for the staff person in charge will be updated to include the duties in case of emergencies, processes for communicating changes in condition and care needs, as well as the procedures and responsibilities to follow in the event of incidents. The Executive Director and/or the Business Office Director will complete this by 11/30/24. Additional Corrective Actions: A sample of staff records will be reviewed monthly by the Business Office Director to ensure job descriptions are accurate and signed. Ongoing Quality Assurance Actions: The Executive Director will review the results of these audits during our quarterly QA meetings, beginning with the Q4 2024 review to be held in January 2025.
Standard #:	22VAC40-73-300-B
Complaint related:	No
Description:	Based on facility documentation review, resident record review and staff interview, the facility failed to ensure a method of written communication shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. EVIDENCE: 1. On 10/06/2024, resident 1 was observed by staff person 2 going through an unlocked medication cart on the Dogwood unit in the facility?s safe, secure unit. 2. Communication logs and resident staff/progress notes provided by staff person 3 on 10/21/2024 did not contain any documentation of this incident involving resident 1. Staff person 3 confirmed this is accurate.
Plan of Correction:	Immediate Corrective Actions: Care staff will be in-serviced by the Executive Director and Resident Care Director on November 15, 2024, on the procedures necessary for effective and clear communication on changes in the resident?s change in condition, injuries, incidents and/or complaints so all shifts can be informed. This will include use of the Communication Log. Additional Corrective Actions: The Executive Director and Resident Care Director will review the communication logs several times daily for changes in residents and care needs and will ensure the care staff are aware of such changes. These changes will also be documented accordingly in resident notes and care plans. Ongoing Quality Assurance Actions: The Executive Director will review compliance regarding communication documentation during our quarterly QA meetings, beginning with the Q4 2024 review to be held in January 2025.
Standard #:	22VAC40-73-660-A-1
Complaint related:	Yes
Description:	Based on staff interview, the facility failed to ensure a medicine cabinet, container, or compartment that is used for storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility shall be locked. EVIDENCE: 1. The licensing inspector (LI) received a complaint on 10/10/2024 with information that resident 1 was observed going through an unlocked, open medication cart in the facility?s safe, secure unit on the Dogwood unit around 1:30PM on 10/06/2024. 2. Interview with staff person 2 on 10/21/2024 revealed that they observed the resident opening drawers of the medication cart and proceeded to lock the medication cart and alerted staff persons 1 and 4 of the incident. 3. Interview with staff person 1 on 10/21/2024 revealed that they were the registered medication aide (RMA) on duty on 10/06/2024 and responsible for the medication cart on the Dogwood unit in the safe, secure unit. Staff person 1 stated that they were alerted by staff person 2 that they observed resident 1 opening drawers of the medication cart on the Dogwood unit and that staff person 2 had to lock the medication cart because it was unlocked.
Plan of Correction:	Immediate Corrective Actions: The medication aide completed a medication refresher course on 10/16/24 including a review of medication management policies and procedures with Resident Care Director. Additional Corrective Actions: All medication aides will complete the medication aide refresher course by November 15,2024, conducted by Fresh Start. The Resident Care Director will conduct training for all medication aides on November 1, 2024, reviewing the policies and procedures for medication administration. Ongoing Quality Assurance Actions: Starting 10/28/24, the Executive Director and/or Resident Care Director will round the facility at least three times per day to ensure the medications are properly locked as stated in our medication management plan. Weekly medication cart audits will be completed by the Resident Care Director or Memory Care Coordinator to ensure the medication carts are locked while unattended, beginning 10/28/24. During the monthly nursing meeting, the Resident Care Director will review the weekly cart audits and review their findings, beginning with the November meeting. The Executive Director will use monthly audits to measure compliance, and the results will be reviewed during our quarterly QA meeting, beginning with the Q4 2024 review to be held in January 2025.