VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Heritage Green Assisted Living
7080 Brooks Farm Road
Mechanicsville, VA 23111
(804) 746-7370

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: May 12, 2021

Complaint Related: No

Areas Reviewed:

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 EMERGENCY PREPAREDNESS

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 5/12/2021 and concluded on 5/14/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that there are 66 residents in care. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed five (5) resident records, five (5) staff records, fire and health inspection reports, health care oversight, medication administration records, physician orders, staff schedules, emergency procedures, etc. submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations are documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on a review of documentation for five residents during a remote inspection, the comprehensive service plan for one resident failed to accurately describe the resident's identified needs based upon the UAI (uniform assessment instrument) and physician orders. Evidence: 1. The UAI states under medication administration "administer/monitor by professional nursing staff". The comprehensive service plan for resident # 4 dated 2/19/2021 states: "Medication management done by _____(resident) and her daughter. 2. Physician orders for resident # 4 note DNR status. The comprehensive service plan for resident # 4 dated 2/19/2021 does not address the DNR status. 3. Physician orders for resident # 5 note "mechanical soft" diet. The ISP (individualized service plan) for resident # 5 dated 4/14/2021 addresses a "puree" diet.
Plan of Correction:	UAI and ISP for resident 4 and 5 was updated to include identified need and what type of assistance staff are to provide to include coordinated services. Community will continue to complete preliminary and comprehensive ISPs in conjunction with resident, staff and family members to ensure the basic needs of the resident are being met. ED and RCD or designee will review ISPs to ensure compliance.
Standard #:	22VAC40-73-680-D
Description:	Based on a review of medication administration records for five residents during a remote inspection on 5/14/2021, medications were not administered in accordance with the physician's or other prescriber's instructions for one resident. Evidence: Resident # 2 - The physician order and medication administration record (MAR) for Potassium 10 meg states "take one tablet by mouth every 12 hours". The medication was not administered every 12 hours as the MAR documents Potassium 10 meg being administered at 7am and 5 pm from 5/4/21 through 5/13/21.
Plan of Correction:	RCD or designee will re-educate all RMAs or nurses on adherence to the rights of medication administration to include medications being administered in accordance with the physician order.