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 11, 2022

Complaint Related: No

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/11/2022, 8:26 a.m. to 2:15 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview with staff, the facility failed to ensure the comprehensive individualized service plan (ISP) included a description of identified needs and date identified based upon the Uniform Assessment Instrument (UAI). Evidence: 1. The following residents? comprehensive ISPs did not include identified needs based on their current UAIs: A. Resident #1 admitted 4-27-2022. Resident #1?s ISP dated 4-28-2022 documented under bathing, ?will receive physical assistance with showering 2 x weekly and as needed Resident needs physical assistance with showering back and lower portion of body only?; however, the resident?s UAI dated 4-27-2022 documented the resident requires ?mechanical help and human help physical assistance?. Additionally, ISP documented under toileting, ?Physical assist for toileting as needed to decrease incontinent episodes?; but the UAI documented the resident needs ?no? help with toileting. The ISP documented under transferring (supervision assistance), ?Resident has been instructed to notify staff when they are going to transfer from on location to another so staff can be present to supervise? but the UAI documented the resident needs ?no? help with transferring. The resident?s ISP documented under incontinent care (bladder less than weekly), ?Less than weekly for bladder Wears disposable briefs, change disposable briefs and clean resident?s skin with soap and water or incontinent wipe after each episode? but the UAI documented no assisted with bladder care. The ISP did not document money management; however, the UAI documented under money management, ?Yes? to needs help. B. Resident #2 admitted 4-12-2021. Resident #2?s ISP dated 4-20-2022 documented under bathing (all aspects) on bath days, ?Will receive physical assistance with showering 2 x weekly and as needed Resident needs physical assist with all aspects of showering, shower preparation and total body wash & dry?; however, the UAI dated 4-04-2022 documented the resident receives ?mechanical and human help physical assistance?. The ISP documented under dressing (self), ?self, without assistance from staff? but the UAI documented the resident receives ?human help supervision?. The ISP documented under walking (assist X1) (and mechanical device) in her room, ?Physically assist of 1 with ambulation with walker and/or cane? and under wheeling (assist) is wheeled by the staff to and from the dining room, ?Will receive physical assistance with propelling wheelchair; however, the UAI for both walking and wheeling says ?Yes? for assistance with no specified assistance type. C. Resident #3 admitted 3-17-2022. Resident #3?s ISP dated 4-19-2022 documented under mobility (self), ?Resident needs no assistance when going outside of the facility?; however, the UAI documented, ?mechanical and human help, physical assistance? under mobility. D. Resident #4 admitted 2-24-2021. Resident #4?s ISP dated 2-24-2022 documented bathing (supervision), ?Supervise resident with adjusting water temperature and provide stand by supervision should resident have any additional needs. Stand by assistance in and out of the shower as desires he will let staff know when he is ready?; however, the UAI dated 2-11-2022 documented, ?No? under needs help for bathing. Additionally, the ISP documented under transferring (with mechanical device), ?Resident is able to transfer self with the assistance of their CANE/WALKER without assistance or supervision from staff?; however, the UAI documented ?No? under needs help for transferring. (Continued and documented off violation notice)
Plan of Correction:	Resident Care Director / Memory Care Director or designee will review the ISP to ensure that all UAI and ISP are mirrored images of one another. All records have been corrected. Executive Director will ensure this during routine monthly audits as part of the overall Quality Assurance program. Monthly QA audits will be completed by the Resident Care Director and reviewed at the Quarterly QA meeting
Standard #:	22VAC40-73-640-A
Description:	Based on record review, the facility failed to ensure to implement a written plan for medication management including methods to ensure that each resident's prescription medications and any over- the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: 1. Resident #3?s Notes on 4-17-2022 at 9:13 p.m. documented, ??. [facility staff] called [resident physician?s] office and was connected to the on call doctor?. Explained that [resident #3] missed a dose of her Oxycodone and needed a new order or a refill?? 2. Resident #3?s April 2022 MAR documented Resident #3 missed the 4-16-2022 dose at 9:00 p.m., ?waiting on pharmacy? as reason given. 3. The facility?s ?Best Practice Manual? for the facility?s medication management plan updated December 2020 documented, ?Missed meds ~ this will default to the previous day. You can use the drop box to pull back 3 days, 7 days or 30 days. (If you find a missed medication, you must reach out to med tech that was on duty to determine the cause, do not insert your comment, let the med tech on duty) Determine if this is a reportable. If alerts are being managed and the dashboard is being reviewed, this should happen rarely. If an alert shows and the med tech cannot find the medication in the cart, he/she Must notify the Resident Care Director or Memory Care Director immediately so a search for the medication can begin and if not found ordered STAT so the resident doesn?t miss their dose?? 4. Staff #1 confirmed that the Best Practice Manual is what is followed as far as ensuring medications are filled and refilled to ensure there are not missed doses.
Plan of Correction:	A reconciliation of resident # 3 medication was completed to ensure availability of all medications. The RCD completed a training with the medication administration staff on following all directives of the physician order and HG medication reordering process.
Standard #:	22VAC40-73-650-A
Description:	Based on record review, the facility failed to ensure no medication was changed without a valid order from a physician or other prescriber. Evidence: 1. Resident #1?s medication administration observation observed by licensing staff on 5-11-2022 was resident received Gabapentin 100 mg at approximately 9:26 a.m. 2. Resident #1?s April 2022 Medication Administration Record (MAR) documented Resident #1 receives ?Gabapentin 100 mg capsule, 1 capsule by mouth four times a day.? 3. Resident #1?s physician?s orders dated 4-13-2022 documented ?Gabapentin 300 mg 1 cap 4 times daily CVA?. 4. Staff #1 confirmed the aforementioned information.
Plan of Correction:	All resident records have been audited and corrected by the MCD and RCD to ensure the MD orders are present and orders are now approved by RCD or MCD and compared to the physician order before the medication is placed on the MAR. Monthly audits will be completed by RCD and MCD or designee to ensure MD orders are followed RCD and MCD or designee will monitor monthly QA and review quarterly at the QA meeting.
Standard #:	22VAC40-73-980-H
Description:	Based on observation and interview with staff, the facility failed to ensure that at least 48 hours of the emergency drinking water supply was on site at any given time. Evidence: 1. During a facility tour with Staff #3, Staff #3 indicated that there was no emergency water onsite and that ?we contract with others? and provided a list of vendors the facility is working with. 2. Staff #1 confirmed during interview the water supply was not onsite on 5-11-2022.
Plan of Correction:	DSD has ordered 48 hours? worth of water for Emergency supplies and will continue to have the required Emergency water on site at all times. DSD or designee will do a periodic review quarterly to track the water supply.
Standard #:	22VAC40-90-30-C
Description:	Based on observation and interview with staff, the facility failed to ensure any person did not make a materially false statement on the sworn statement. Evidence: 1. Staff #1 (criminal record checks)?s date of hire is 9-09-2021. Staff #1 stated, ?No? for the question: ?Have you ever been convicted of a crime within or outside Virginia (but excluding offenses committed before your eighteenth birthday that were finally adjudicated in a juvenile court or under a youth offender law?? on the sworn statement dated 9-07-2021; however, the staff person had been convicted of a crime per their Criminal History Request Response dated 9-07-2021. 2. Staff #1 acknowledged Staff #1 (criminal record checks) made a materially false statement on the sworn statement.
Plan of Correction:	BOM or designee will ensure any new staff member will complete accurately a written Sworn disclosure upon the date of hire. 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.