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: March 26, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 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: 03/26/2024 1:38pm-3:00pm 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 03/06/2024 regarding allegations in the area(s) of: Staffing and Supervision and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 96 Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: The facility was having an Easter program for the residents during the visit. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at Shelby.Haskins@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1040-A
Description:	Based on staff interviews and review of resident record, the facility failed to ensure that a system of monitoring the resident with a history of wandering behaviors was followed in order to prohibit exiting (eloping) the facility. Evidence: 1. Resident?s Individual Service Plan (ISP) dated 01/12/2024 noted that the resident has a history of wandering behaviors. 2. Staff #2 acknowledged that the staff on duty did not follow their own policy for checking resident?s Wander Guard safety to prevent elopement as resident #1 was able to leave the facility without any alert to staff.
Plan of Correction:	Resident?s Medication Administration Record was updated to reflect wander guard placement with visual verification of wander guard placement and functionality to be completed each shift. Resident?s Medication Administration Record was updated to reflect wander guard placement with visual verification of wander guard placement and functionality to be completed each shift. Resident and family have been educated as to the need for egress monitoring device. No further exit seeking behavior has been observed. The wander guard system is monitored daily by our maintenance team for functionality while the system itself sends a daily report on function, tampering or low batteries. Periodic audits to verify documentation, placement of devices and functionality will be conducted. Staff training audits will be reviewed at Quarterly QA meetings beginning in Q2 Staff responsible: Registered Medication Aides, Care Aides, Resident Care Director, Executive Director and Maintenance Team.
Standard #:	22VAC40-73-460-D
Description:	Based on a review of documentation and staff interviews, it was determined that the facility failed to provide the supervision of resident?s schedule, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises. Evidence: 1. A self-report was received by the Licensing Inspector on 3/6/24 that indicated that on 3/5/24 resident #1 left the facility at 6:15pm and was found along Lee Davis Road by staff. 2. Staff #1 informed inspector that the resident had taken off his Wander Guard prior to eloping from the premises.
Plan of Correction:	Resident was redirected back into the community at the time of incident by Heritage Green Staff. Resident was examined for any signs of injury, none were noted. Resident?s wander guard was re-placed by Registered Medication Aide and family notified. Audit conducted on all residents with wander guard device to verify function and placement. Staff training audits will be reviewed at the Quarterly QA meetings beginning Q2. All wander guard orders will be documented on Medication Administration Record and checked each shift for placement and function. Staff responsible: Care Aides, Registered Medication Aide, Memory Care Director and Executive Director