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 16, 2019

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 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 Licensure and Registration Procedures 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 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 SANCTIONS.

Comments:

An unannounced renewal inspection was conducted at the facility by two licensing inspectors on 5/16/2019 from approximately 2:00 pm to 4:30 pm. The facility had 74 residents in care on the date of the inspection. Ten resident files and five staff files were reviewed for compliance. along with other required program documentation. All new personnel records were reviewed since the last inspection for criminal history record reports and all were in compliance. See violation notice for non-compliancies. The facility has 10 calendar days from receipt of the inspection reports to complete a plan of correction, sign the inspection reports and return them to the licensing office. A copy of the inspection reports shall be retained to be posted at the facility. Results of the inspection are subject to public disclosure and will be posted on the VDSS website within 15 calendar, regardless of whether the plan of correction is completed .Just writing the word ?corrected? is not acceptable. The plan of correction shall include the following: (1) Step(s) the facility will take to correct the violations cited; (2) Measures that will be put in place to prevent reoccurrence of each violation; (3) Person(s) responsible for implementation and monitoring of preventive measures; and (4) Date by which each violation will be corrected.

Violations:

Standard #:	22VAC40-73-1100-A
Description:	Based on a review of ten resident files, one resident was placed in a safe, secure environment without written prior approval. Evidence: Documentation of a written approval was not found during a review of the file for resident # 1
Plan of Correction:	Written approval will be supplied and reviewed with all residents that move into the secured unit. We will have quarterly audits to ensure that all residents have the written approval in their charts reviewed and signed by their responsible party. Charts have already been audited of residents that reside in the special care unit and all have been corrected on this date of 5/23/2019.
Standard #:	22VAC40-73-720-A
Description:	Based on a review of ten resident files, a do not resuscitate order for one resident was not reflected on the resident's individualized service plan. Evidence: A review of the file for resident # 3 found a do not resuscitate order (DNR) dated 5/21/18. The resident's current service plan dated 11/5/18 did not include the DNR.
Plan of Correction:	As DNR orders come into the community, the nurse or designee will make sure that the order is fulfilled and the DNR status will be changed on the ISP to reflect this change. An audit has already been made of all the resident charts and have all been corrected on this date of 5/23/2019.