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. 29, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/29/2022 9:46AM until 12:00PM 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 08/20/2022 regarding allegations in the area of: resident care and related services. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-460-E
Description:	Based on resident record review and staff interview, the facility failed to document a notable change in a resident?s condition or functioning in the resident?s record. EVIDENCE: Staff 3 sent the following self-reported incident to the regional license office on 08/21/2022 regarding resident 1: ?Resident was observed on 08/20/2022 with bilateral leg edema, RMA (registered medication aide) went to remove residents shoes and socks and observed wound to R (right) top of foot with foul odor and drainage, resident was sent to the hospital for evaluation due to possible infection.? and ?Resident admitted to the hosp. for Osteomyelitis?. Staff 1 was identified as in charge of washing the resident?s laundry at the facility. During on-site inspection on 08/29/2022, staff 1 revealed to the licensing inspector (LI) and staff 3 that she had found four pairs of ?balled up socks? in resident 1?s dirty clothes on either 08/16/2022 or 08/17/2022 and that she had to ?soak the pairs of socks in peroxide? due to the condition they were in and the socks ?smelt really bad? and ?smelt like death?. Staff stated that she informed staff 2 about the condition of the resident?s socks because she was concerned something may be wrong with the resident?s feet and wanted to make sure staff checked on the resident?s condition. Staff 2 confirmed to the LI and staff 3 that staff 1 informed her about the resident?s socks on 08/18/2022. Staff 2 stated that she was leaving the facility for the day to go home and didn?t work on 08/19/2022 and revealed that she had not told anyone about staff 1 telling her about the resident?s socks being dirty and smelling bad. The record for resident 1 did not contain any documentation regarding the aforementioned information from staff 1 and 2.
Plan of Correction:	How: Staff training will be conducted by 9/30/22 to review when to document any changes of condition in resident?s record upon notification. Ongoing: RCD or designee will monitor communication log daily and take appropriate measures to meet the needs of the resident and will be reviewed during our quarterly QA meeting.