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. 4, 2022

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 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:

Type of inspection: Renewal Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 10/04/2022 8:30AM until 5:15PM 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: 105 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: 5 Number of interviews conducted with staff: 4 Observations by licensing inspector: medication passes, medication cart audits, one activity, dietary postings in the kitchen 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 Jennifer Stokes, Licensing Inspector at (540) 589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-325-B
Description:	Based on resident record review, the facility failed to ensure that the fall risk rating shall be reviewed and updated after a fall and annually. EVIDENCE: 1. The record for resident 3 contained staff notes regarding a fall that occurred on the evening of 09/15/2022; however, the most current fall risk rating for resident 3 was dated 04/15/2022 that was provided by staff 7 during on-site inspection. 2. The record for resident 5 contained staff notes regarding a fall that occurred on the 09/16/2022; however, the most current fall risk rating for resident 5 was dated 07/02/2021 that was provided by staff 7 during on-site inspection. 3. The most current fall risk rating for resident 9 that was provided by staff 7 during on-site inspection was dated 06/21/2021.
Plan of Correction:	How: The Resident Care Director or designee will transfer all updated fall risk ratings to the electronic system. Ongoing: The Executive Director or designee will monitor the completion of the falls risk ratings during our weekly falls meeting and annually as stated in the standards. This will be reviewed during our quarterly QA meeting for compliance.
Standard #:	22VAC40-73-610-D
Description:	Based on resident record review, observation and staff interview, the facility failed to ensure that when a diet is prescribed for a resident by his physician or other prescriber, it is prepared and served according to the order. EVIDENCE: The report of resident physical examination for resident 7, dated and signed by a physician on 08/23/2022, contained documentation that the resident is on a no concentrated sweets (NCS) diet. During on-site inspection on 10/04/2022, the listing in the kitchen at approximately 10:02AM, dated 09/30/2022, contained documentation that the resident is being served a regular diet and contained no documentation that the resident receives a NCS diet. Interview with staff 6 confirmed that the listing in the kitchen is what the kitchen staff use to serve meals to the residents and that resident 7 has been receiving a regular diet.
Plan of Correction:	How: Dietary Services Director updated the menu board in the kitchen to reflect the current order on the History & Physical. Ongoing: The Executive Director or designee will give a copy of the current diet order to the dietary department upon new admissions or when there is a diet change. This will be reviewed during our quarterly QA meeting for compliance.
Standard #:	22VAC40-73-640-A
Description:	Based on resident record review, observation, and staff interview, the facility failed to implement its medication management plan (MMP). EVIDENCE: 1. The facility?s medication management plan (MMP) states that ?the individual responsible for medication administration shall keep the keys to the storage area on his person.? During on-site inspection on 10/04/2022 at approximately 10:14AM, one licensing inspector (LI) noted that the keys to medication cart 200 & 400 were in the lock and the cart was noted to be unlocked. Staff 1 revealed to the LI that she had left the aforementioned keys in the lock of the medication cart and left the cart unattended. 2. The facility?s MMP states the following: ?RCD and/or ARCD look at the EMAR to ensure the pharmacy has noted it correctly for all new orders after they have been faxed to the pharmacy. Orders can be e-scribed by the physician or they are faxed to the pharmacy by Heritage Green staff.? The record for resident 9 contained the following electronically signed physician?s noted dated 09/26/2022 at 2:05PM: ?Assessment & Plan: 1) Seasonal allergic rhinitis: +Loratadine 10mg daily x 14 days. + Fluticason 0.05mg/actuation nasal spray ? 1 spray in each nostril q12h PRN for nasal congestion. Electronically signed by: (physician) and note dated 09/26/2022 at 3:45PM by staff 9: ?Resident with complaints of allergy symptoms and nasal congestion. NP made aware and new orders received for Loratadine 10mg po daily for 14 days, Flonase nasal spray every 12 hours as needed. Residents son made aware of new orders.? During on-site inspection on 10/04/2022 it was determined and verified by staff 7 that the physician is to fax orders to the pharmacy; however, the two aforementioned medications were not in the facility on date of inspection and no follow-up from facility staff had been made. 3. The facility?s MMP states the following: ?Medications with shortened expiration dates once opened, such as some insulins for example, need open and discontinued dates on them.? and ?When required, medications shall be refrigerated.? Medication cart 200 & 400 contained the following: an open vial of Lantus for resident 13; however, the vial nor the box for the Lantus contained an open date and an unopened bottle of liquid Lorazepam for resident 2; however, the manufacturer?s instructions state that this medication must be refrigerated at 2 degrees to 8 degrees Celsius. This was also observed by staff 1. 4. The facility?s MMP states the following: ?Methods to prevent the use of outdated, damaged or contaminated medications: An LPN must be present to destroy controlled drugs, if they cannot be returned to the pharmacy.? and ?Two staff must be present during destruction of medications, if a narcotic is being destroyed one of the two must be a licensed nurse.? During on-site inspection it was revealed to one licensing inspector by staff 1 that staff 1 wasted one capsule of Gabapentin during her morning medication pass on 10/04/2022, which is a controlled substance, and did not waste the Gabapentin with a witness. The LI had witnessed staff 1 throw a pill cup of pills away in the trash on the side of the medication cart and staff 1 stated it contained the one capsule of Gabapentin.
Plan of Correction:	1. How: Medication aide corrected upon awareness and put the med cart keys in her pocket. The Executive Director re-educated the medication aide on keeping the med keys on her person at all times. Resident Care Director conducted a medication aide meeting on 10/6/22 and reviewed the policy of keeping the keys on their person at all times. Ongoing: The Resident Care Director or designee will routinely monitor medication aides during medication passes to ensure they are following our Medication Management Plan. This will be reviewed during our quarterly QA meeting for continued compliance. 2. How: The Wellness Nurse or designee will review all new orders, send to pharmacy, put the orders in a follow-up folder, daily monitor the QuickMar dashboard to ensure new orders have been transcribed into the electronic MAR system, approve the order before filing into the electronic chart. Ongoing: The Resident Care Director or designee will review QuickMar dashboard daily for new orders. Weekly medication cart audits will be conducted by the Resident Care Director or designee to ensure medications are present and administered in accordance to the MD orders. This will be reviewed during our quarterly QA meeting for continued compliance. 3. How: The Medication Aide checked and corrected the date on the Lantus vial. A new order was obtained to discontinued the Lorazepam concentrate due to non-usage. Resident Care Director conducted a medication aide meeting on 10/6/22 and reviewed all opened bottles are properly dated and any refrigerated medications are properly stored. Ongoing: The Resident Care Director or designee will complete weekly medication cart audits to ensure all medications are dated and/or refrigerated as needed. This will be reviewed during our quarterly QA meeting for continued compliance. 4. How: The Medication aide was educated by the Executive Director on 10/4/22 regarding the correct procedures in destroying medications in accordance to our Medication Manual Plan. Ongoing: The Resident Care Director conducted a medication aide meeting on 10/6/22 and reviewed appropriate destruction of medications according to our Medication Management Plan. This will be reviewed during our quarterly QA meeting for continued compliance.
Standard #:	22VAC40-73-680-D
Description:	Based on observation during morning medication administration, the facility failed to ensure that a registered medication aide (RMA) was administering medications consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: During the morning medication pass on 10/04/2022, one licensing inspector (LI) observed staff 1 administering medications to residents and not wearing identification as required by the Board of Nursing Regulations Governing Medication Aides, which is covered in Chapter 1, Objective 1.3 of the current RMA curriculum approved by the Virginia Board of Nursing. Staff 2 confirmed that she had left her name tag in her car.
Plan of Correction:	How: Medication aide placed her name badge on during the inspection. Re-education given to the medication aide for proper identification upon arrival. The Resident Care Director conducted a medication aide meeting on 10/6/22 and reviewed the Medication Management Plan regarding wearing name badges. Ongoing: The Executive Director or designee will check all staff daily for proper identification during working hours. This will be reviewed during our quarterly QA meeting for continued compliance.
Standard #:	22VAC40-73-860-I
Description:	Based on observation during a tour of the facility?s physical plant, the facility failed to ensure cleaning supplies and other hazardous materials were in a locked area. EVIDENCE: At approximately 9:49AM during on-site inspection on 10/04/2022, one licensing inspector (LI) noted that the door to the laundry room located near the dining room was unlocked and there was no staff present in the laundry room. The laundry room contained multiple cleaning supplies such as glass cleaner, Resolve pet stain spray, furniture polish, Monogram disinfectant bleach, and Zep bleach resistant spray.
Plan of Correction:	How: The Maintenance Director applied an automatic closure to the laundry door to assist in ensuring the door shuts when staff exits the room. The laundry staff training was conducted on 10/11/22 to review procedures on ensuring the laundry door is closed when unoccupied. Ongoing: Executive Director, Maintenance Director or designee will monitor compliance with this new process daily and will be reviewed during our quarterly QA meeting.
Standard #:	22VAC40-73-980-C
Description:	Based on observation, the facility failed to ensure that first aid kits were checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. EVIDENCE: Upon review of the contents of the first aid kit in the Dogwood unit, one licensing inspector (LI) observed that the first aid kit checklist had not been completed since July (year not specified).
Plan of Correction:	How: The Resident Care Director or designee updated the first aid checklist for the Dogwood first aid kit. Ongoing: The Resident Care Director or designee will ensure all first aid kits for each neighborhood are updated monthly. This will be reviewed during our quarterly QA meeting for compliance.