VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Heritage Green Assisted Living Communities
201 & 202 Lillian Lane
Lynchburg, VA 24502
(434) 385-5102

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Oct. 2, 2019 and Nov. 8, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

On 10/2/2019 one inspector began a complaint investigation (3AM to 4AM) regarding lack of resident care, violence, and third shift memory care staff sleeping. The inspection was completed off site, with the final day 11/8/2019. The Li observed staff actively engaged in cleaning residents and putting dry sheets on the bed. Another agency investigated the allegations of violence and was unable to find evidence to support that allegation. The LI reviewed the staff schedule with the date of the alleged incident, and the alleged perpetrator was not on duty at the time. The LI did note a staff person wrapped in a blanket before the LI was allowed into the building, and anonymous interviews with staff (two of three interviewed) named the same people as being seen asleep more than once during third shift. There is no evidence to support the allegations of neglect or abuse, but there is evidence to support that staff were asleep during third shift on the memory care unit. The complaint is valid. During the inspection and at the exit interview, the facility was given the opportunity to discuss the violations and to show that they were in compliance. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain the following: 1) steps to correct the noncompliance with the standard(s); 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions, please contact your licensing inspector at 540-309-3043.

Violations:

Standard #:	22VAC40-73-1130-A
Complaint related:	Yes
Description:	Based on staff interviews and document review, the facility failed to have sufficient staff awake and on duty in the special care unit. EVIDENCE: 1. Based on anonymous staff interviews, two of three direct care staff interviewed stated they have seen staff members asleep while on duty in the special care unit. The facility has a staffing pattern of 5 direct care on duty during third shift, according to the August and September staff schedules, with an average of 49 residents on the memory care unit, according the the administrator.
Plan of Correction:	Whenever we, at Heritage Green, are aware of a complaint regarding staff?s performance we follow the appropriate path of corrective action. While, there was no evidence of anyone sleeping when the inspector made an in person, unannounced visit on 3rd shift as part of an anonymous complaint to DSS, upon receiving knowledge of this complaint, the Executive Director and Resident Care Director conducted staff interviews as well. Two staff, who were alleged by others to sleeping, received the appropriate level of corrective action. At random intervals for the next 30 days the ED or designee will make unannounced visits between the hours of midnight and 5 am ensure all staff are providing appropriate care and not sleeping.