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 10, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 05/10/2024 arrival time 10:05am departure time 3:05pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Lunch, weekly menu and resident activities were observed. A medication pass observation was completed. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: Inspector observed some of the residents engaged in an activity acknowledging Mother?s Day. An exit meeting will be conducted to review the inspection findings. 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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at Shelby.Haskins@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-310-D
Description:	Based on a review of resident records, it was determined that the facility did not ensure to provide written assurance to residents that the facility has the appropriate license to meet their care needs at this time of admission. Copies of the written assurance shall be given to the legal representative and case manager, if any, and a copy signed by the resident, or his legal representative shall be kept in the resident?s record. Evidence: 1. The Written Assurance was not present in the record of resident #2. 2. The Written Assurance was not present in the record of resident #3. 3. Staff # 6 reviewed the records for resident #2 and resident #3 and was unable to provide documentation of the written assurance for either resident during the onsite inspection.
Plan of Correction:	Immediate Corrective Actions ? The Executive Director will have completed the Written Assurance for Residents #2 and #3 on or by 5/25/2024. Additional Corrective Actions ? The Executive Director and Clinical Care Coordinator will complete an audit of all resident records to ensure the Written Assurance is present. Any missing Written Assurance documentation will be completed by the Clinical Care Director by 6/15/2024. Ongoing Quality Assurance Actions - The Executive Director or designee will review a sample of resident records 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 July 2024, scheduled to review the second quarter documentation.
Standard #:	22VAC40-73-320-B
Description:	Based on a review of resident records, it was determined that the facility did not ensure that that a risk assess for tuberculosis shall be completed annually on each resident. Evidence: 1. The record for resident #3 contained a tuberculosis evaluation that was dated 3/4/23. 2. The record for resident #7 contained a tuberculosis evaluation that was dated 4/3/23. 3. Staff #6 reviewed the records for resident #3 and resident #7, and confirmed that an annual tuberculosis assessment had not been completed for either resident.
Plan of Correction:	Immediate Corrective Actions ? The Executive Director will obtain updated tuberculosis evaluations for Residents #3 and #7 by 6/15/2024. Additional Corrective Actions ? The Clinical Care Coordinator will complete an audit of all resident records to ensure tuberculosis evaluations are up to date. Any that are found to be outdated will be completed by 6/15/2024. Ongoing Quality Assurance Actions - The Executive Director will review a sample of resident records 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 July 2024, scheduled to review the second quarter documentation.
Standard #:	22VAC40-73-720-A
Description:	Based on a review of resident record, it was determined that the facility did not ensure that a valid written Do Not Resuscitate Order (DNR) for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest may only be carried out in a licensed assisted living facility. Evidence: 1. The Do Not Resuscitate order that was in the record for resident #4 was not signed by the physician. 2. Staff #6 was unable to provide a signed written Do Not Resuscitate Order (DNR).
Plan of Correction:	Plan of Correction: Immediate Corrective Actions ? The Executive Director obtained fully completed DNR Orders for Residents #4 and #6 on 5/18/2024. Additional Corrective Actions ? The Executive Director will audit all resident records to ensure that DNR Orders are signed and fully completed. This audit will be completed by 6/15/2024. Any Orders found to be incomplete, will be addressed by the Executive Director, and will be completed by 6/30/2024. Ongoing Quality Assurance Actions - The Executive Director will review a sample of resident records 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 July 2024, scheduled to review the second quarter documentation.
Standard #:	22VAC40-73-980-A
Description:	Based on a review of the facility?s First Aid Kit, it was determined that the facility did not ensure a complete first aid kit shall be on hand in each building of the facility with all the required items. Evidence: 1. The facility did not have a blanket and a pair of scissors in the First Aid Kit 2. Staff #6 acknowledged that the first aid kit for the facility did not contain all of the required items.
Plan of Correction:	Immediate Corrective Actions ? On 5/10/2024, the Executive Director reviewed the First Aid Kit contents and added a blanket and pair of scissors, to ensure all required items are present. Additional Corrective Actions ? On 5/10/2024, the Clinical Care Coordinator was educated by the Executive Director to ensure they complete the monthly check of the First Aid Kit and complete the monthly checklist, to ensure all required items are present. At any time, if items are missing, the Clinical Care Coordinator will replenish those supplies. The Clinical Care Coordinator will complete the monthly checklist, beginning in May 2024. Ongoing Quality Assurance Actions - The Executive Director will review the monthly checklist as part of the Quarterly Quality Assurance Meeting to ensure compliance and review any concerns or trends. This will begin with the Quarterly Meeting in July 2024, scheduled to review the second quarter documentation.
Standard #:	22VAC40-73-980-C
Description:	Based on a review of the facility?s First Aid Kit, it was determined that the facility did not ensure that the first aid kits shall be checked at least monthly to ensure that all items are present. Evidence: 1. The facility had a monthly checklist inside of the First Aid Kit in which the month of April 2024 the First Aid Kit was not checked for compliance. 2. Staff #6 acknowledged that the monthly checklist for the first aid kit for the facility was not completed for April 2024.
Plan of Correction:	Immediate Corrective Actions ? On 5/10/2024, the Executive Director reviewed the First Aid Kit contents and added a blanket and pair of scissors, to ensure all required items are present. Additional Corrective Actions ? On 5/10/2024, the Clinical Care Coordinator was educated by the Executive Director to ensure they complete the monthly check of the First Aid Kit and complete the monthly checklist, to ensure all required items are present. At any time, if items are missing, the Clinical Care Coordinator will replenish those supplies. The Clinical Care Coordinator will complete the monthly checklist, beginning in May 2024. Ongoing Quality Assurance Actions - The Executive Director will review the monthly checklist as part of the Quarterly Quality Assurance Meeting to ensure compliance and review any concerns or trends. This will begin with the Quarterly Meeting in July 2024, scheduled to review the second quarter documentation.