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: Aug. 18, 2020

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 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 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 08/17/2020 and concluded on 08/18/2020. The administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 99. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 5 resident records, 5 staff records, staff schedule for safe secure unit and assisted living, dietary review, health care oversight, and fire and emergency evacuation drills submitted by the facility to ensure documentation was complete. The LI and the Administrator had a discussion regarding standards 930 D and 680 E. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure that physical examinations were completed as required prior to a resident?s admission. EVIDENCE 1. The ?REPORT OF RESIDENT PHYSICIAN EXAMINATION? for resident 2, dated 07/26/2020, did not contain a statement that specifies whether the resident is or is not capable of self-administering medication.
Plan of Correction:	What: Resident 2?s ?Report of Resident Physician Examination? was completed by the skilled nursing facility where she was a resident prior to admission to Heritage Green. The completed form did not contain documentation indicating that the resident is or is not capable of self-administering medication. Resident is not self-administering medication. How: Resident physician assessed resident 8/20/2020 and updated the ?Report of Resident Physician Examination? as not being capable of self-administering medication. Ongoing: Prior to resident move-in, all required admission forms will be reviewed by the Resident Care Director / Memory Care Director, or designee, to ensure that all required documentation is complete and accurate. Monthly QA audits will be completed by the Resident Care Director and reviewed at the Quarterly QA meeting.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure residents? individualized service plan (ISP) included all required components. EVIDENCE: 1. The current ISP for resident 2 shows the resident started receiving occupational therapy on 08/04/2020, physical therapy on 08/03/2020 and wound care 08/15/2020; however the ISP does not indicate the agency that is providing the services. Interview with staff 1 revealed that Fox Rehab is providing occupational and physical therapy and Amedisys Home Health is providing wound care to resident 2. 2. The ISP for resident 1, dated 03/13/2020, showed the resident is receiving hospice; however the ISP does not show which agency is providing hospice services. Interview with staff 1 revealed resident 1 is receiving hospice services from Centra Hospice. The record for resident 1 contained a physician?s order, dated 06/25/2020, for ?OXYGEN; O2 VIA NASAL CANULA AT 2 LITERS VIA CONCENTRATOR AND TAKE AS NEEDED?. The ISP for resident 1 stated ?oxygen will be kept at level as ordered by their Physician? but does not include a written description of the specific services provided. 3. The record for resident 3 contained a physician?s order, dated 06/30/2020, for ?OXYGEN; 02 AT 2L PER NASAL CANNULA AND NEEDED. MAY USE TANK OR CONCERNTRATOR?. The ISP for resident 3, dated 11/06/2019, stated ?oxygen will be kept at level as ordered by their Physician? but does not include a written description of the specific services provided. 4. The current ISP for resident 5 shows the resident started receiving occupational therapy on 04/22/2020 and physical therapy on 04/23/2020; however the ISP does not show the agency that is providing the services. Interview with staff 1 revealed that Fox Rehab is providing occupational and physical therapy to resident 5.
Plan of Correction:	What: Resident 2 ISP covers the details of physical and occupational therapy and wound care but does not indicate which home health agency is providing the services. Resident 1 ISP covers the details of hospice care but does not indicate which hospice agency is providing the services. Resident 1 and 3?s ISP lists the need for oxygen but does not include the specific details of the oxygen order. How: Executive Director updated Resident 2?s ISPs to include the specific agency providing the services, Fox and Amedisys and updated Resident 1?s ISP with the specific hospice agency, Centra Hospice. Executive Director updated Resident 1 and 3?s ISPs with the specific details of their oxygen orders. Memory Care Director, Resident Care Director, or designee, and Director of Quality Assurance will be trained on ISP process on September 3, 2020. (Attachment A) Ongoing: Resident Care Director / Memory Care Director or designee will review the ISP to ensure that all providers are properly listed as well as details regarding oxygen use. 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. (Attachment B)
Standard #:	22VAC40-73-680-E
Description:	Based on resident record review and staff interview, the facility failed to ensure a treatment ordered by a physician or other prescriber was provided according to his instructions, documented and maintained in the resident?s record. EVIDENCE: 1. The record for resident 2 contained a physician?s order, dated 08/11/2020, for ?R arm protective sleeve?; however, it did not include documentation that treatment is being provided according to the physician?s instructions. 2. Interview with staff 1 revealed that the arm protective sleeve is to be put on resident 2 in the morning and then taken off at bedtime by staff. 3. The record for resident 5 contained a physician?s order, dated 06/25/2020, for ?BLOOD GLUCOSE MONITORING; MONITOR & RECORD BLOOD GLUCOSE BEFORE MEALS & AT BEDTIME; Schedule: DAILY AT 08:00, DAILY AT 12:00, DAILY AT 17:30, DAILY AT 20:00?. 4. The July 2020 MAR for resident 5 showed that the resident?s blood glucose level was taken and documented by staff at 5:00PM daily from 07/22/2020 through 07/31/2020.
Plan of Correction:	What: Resident 2 had an order 8/11/2020 for ?right arm protective sleeves? that did not appear on the TAR. Resident 5 had an order for blood glucose monitoring before meals and at bedtime. When the pharmacy printed the resident?s orders on a Physician?s Order Form (POF) for physician?s signature on 6/25/2020, the POF included the facility?s medication times of 8:00am, noon, 5:30 pm, and 8:00pm. The pharmacy?s July MAR had the times of 8:00am, noon, 5:30pm, and 8:00pm for staff to document blood sugar monitoring, as well as 5:00pm. From 7/22/2020 ? 7/31/2020 the staff documented the blood sugar monitoring at 5:00pm instead of 5:30 pm, and while it was still before meals, it was not at 5:30pm, the time on the POF. How: Executive Director resent order to the pharmacy for the right arm protective sleeve on 8/19/2020 and it was added to the TAR and staff began documenting that the protective arm sleeve was being put on and taken off. Resident 5?s physician signed a verbal order dated 8/20/20, that blood glucose testing is to be given ?four times a day, before meals, please remove time.? (Attachment C) Ongoing: Resident Care Director / Memory Care Director and/or designee will follow up on all treatment orders utilizing the Best Practice Manual for approving orders. ? (Attachment D) to ensure pharmacy adds the order to the TAR so that staff can document. Executive Director RCD/MCD/Designee will randomly observe that Resident 2 protective sleeve and documentation is in place. Quick Mar documentation will be reviewed per shift utilizing the Quick Mar dashboard to ensure documentation is in place. (Attachment E). Resident Care Director or designee will ensure POF?s are printed without facility medication times for physician signature on orders such as before meals and at bedtime, when a specific medication time is not desired by prescriber or resident. Monthly QA audits will be completed by the Resident Care Director and reviewed at the Quarterly QA Meeting.
Standard #:	22VAC40-73-930-D
Description:	Based on document review, the facility failed to conduct overnight rounds in the safe secure unit for residents unable to use a signaling device. EVIDENCE: 1. The ?SLEEP MONITORING? log for 07/13/2020 for ?DOGWOOD? does not contain documentation that staff made rounds during 8PM and 10PM.
Plan of Correction:	What: 50 resident?s sleep monitoring logs were reviewed for all of July for the hours of 8 pm ? 6 am, every two hours and found to have documentation for 370 of the 372 sleep monitoring times. Dogwood missing documentation on 7/13/2020 for the 8:00pm and 10:00pm rounds. How: Shift Supervisors will ensure that before the end of the shift that sleep monitoring logs are completed. Ongoing: Memory Care Director or designee will review sleep monitoring logs daily. Memory Care Director will review the logs on a weekly basis with the Executive Director as part of the Weekly 1:1 meeting. (Attachment F and G). Monthly QA audits will be completed by the Memory Care Director and reviewed at the Quarterly QA Meeting.