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: June 6, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6-06-2023, 8:57 a.m. ? 12:30 p.m. 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: 71 Number of resident records reviewed: 10 Number of staff records reviewed:3 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 Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based on record review and interview with staff, the facility failed to ensure each direct care staff member maintained current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. To be considered current, first aid certification from community colleges, hospitals, volunteer rescue squads, or fire departments shall have been issued within the past three years. Evidence: Staff #5?s date of hire was 9-09-2021. Staff #5 was working on 6-06-2023 at the time of inspection and did not have a current FA/CPR certification.
Plan of Correction:	Training was completed 6/28/2023. Ongoing BOM will track First Adie and CPR Training dates to ensure compliance. Monthly QA Audits will be completed.
Standard #:	22VAC40-73-320-A
Description:	Based on record review and interview with staff, the facility failed to ensure the physical examination contained a description of the person's reactions to any known allergies. Evidence: 1. Resident #10 admitted 7-27-2022. Resident #10?s physical examination dated 7-13-2022 documented allergies to aspirin, penicillin, sulfa, ceftin, codeine, oxycontin, tramadol, lorazepam, cipro, ace inhibitors, and diclofenac. 2. Resident #4 admitted 3-16-2023. Resident #4?s physical examination dated 3-14-2023 documented allergies to aspirin, diphtheria toxoid, and tetanus immune globulin. 3. Resident #7 admitted 1-16-2023. Resident #7?s physical examination dated 1-09-2023 documented allergies to augmentin, pencillin, morphine, and codeine. 4. The aforementioned three residents? physical examinations did not document descriptions of the persons? reactions to known allergies.
Plan of Correction:	RCD and MCD will review all resident records to ensure a description of any know allergies and reaction are listed. Ongoing RCD and MCD will review Physical Orders prior to filling to make sure know allergies and reaction are listed.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the comprehensive individualized service plan (ISP) included a description of identified needs and date identified based upon the (i) UAI; (ii) admission physical examination; (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (vi) other sources. Evidence: 1. Resident #4 admitted 3-16-2023. Resident #4?s UAI dated 4-01-2023 documented under toileting ?mechanical and human help, physical assistance? and under orientation, ?disoriented to time and place; however, the ISP dated 4-19-2023 did not address ?mechanical help? under toileting, and the ISP did not identify orientation as a service need. 2. Resident #6 admitted 1-11-2023. Resident #6?s UAI dated 1-05-2023 under toileting assistance ?mechanical and human help, physical assistance? and under transferring and eating assistance, ?human help physical assistance; however, the resident?s ISP dated 1-11-2023 for toileting did not address mechanical assistance and did not address transferring or eating help. Additionally, the UAI had for mobility assistance ?human help, physical assistance?; however, the ISP under mobility had ?supervision?. 3. Resident #9 admitted 4-29-2023. Resident #9?s UAI dated 5-25-2023 documented under bathing ?mechanical help?, dressing and toileting ?human help physical assistance?, under behaviors ?appropriate?; and under orientation, ?disoriented to time and place; however, the resident?s ISP dated 6-22-2023 documented under bathing ?mechanical and human help supervision?, under dressing ?human help supervision?, and under toileting ?mechanical help?. Additionally, it did not address orientation of the resident and documented the resident has ?wandering, passive behaviors?. 4. Resident #13 admitted 12-06-2022. Resident #13?s UAI dated 1-05-2023 documented ?yes? under money management assistance; however, the ISP dated 1-17-2023 did not identify money management as a service need.
Plan of Correction:	Fix UAI for identify residents. On monthly bases audit a sample of the residents records to include the UAI for completions and accuracy.
Standard #:	22VAC40-73-450-F
Description:	Based on record review, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. Resident #10 admitted 7-27-2022. The UAI dated 1-05-2023 documented assistance under housekeeping, laundry, and money management was needed; however, the ISP dated 1-17-2023 did not document the service needs. Additionally, the resident?s Face Sheet identified allergies to Aspirin, PCN, Sulfa, Ceftin, Codeine, Oxycontin, Tramadol, Lorazepam, Cipro, Ace inhibitor, and Diclofenac which were not identified on the ISP. 2. Resident #11 admitted 11-10-2021. Resident #11?s UAI dated 5-16-2023 documented resident needs mechanical and human help, supervision with walking; however, the ISP says ?no assist? under walking. Additionally, the resident?s UAI documented under orientation, ?disoriented to time and place?; however, the orientation is not addressed on the ISP.
Plan of Correction:	Fix UAI for identify residents. On monthly bases audit a samples of the residents records to include the UAI for completions and accuracy.
Standard #:	22VAC40-73-680-D
Description:	Based on record review and interview with staff, the facility failed to ensure medications were administered consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. Section 4.1 ?Identify Basic Guidelines for Administering Medications? in the Commonwealth of Virginia Board of Nursing Medication Aide Curriculum for Registered Medication Aides dated 2013 documents, ?13. When administering oral medications, stay with the client until you are certain that the medication has been safely swallowed.? 2. On 6-06-2023 during administration pass observation, Staff #2 gave Resident #1 a medicine cup with Acetaminophen 500 mg and Promethazine 25 mg at approximately 11:15 a.m. Resident #1 did not take the medication in front of Staff #2 nor the licensing inspector, and Staff #2 exited the room prior to the resident swallowing the medication. Staff #2 stated, ?[Resident #1] takes own medications after [Resident #1] eats.? 3. Additionally on 6-06-2023 at approximately 11:20 a.m., Staff #2 gave Resident #2 Vitamin D3 25 mcg in a medicine cup. Staff #2 stated, ?This resident [Resident #2] also takes medication after [Resident #2] eats.? Staff #2 nor licensing inspector witnessed Resident #2 swallow the medications. 4. Staff #3 confirmed that Staff #2 did not follow proper standards of practice regarding medication administration of Resident #1 and Resident #2.
Plan of Correction:	Staff #2 is no longer employed by the community. Ongoing all medication concerns will be reviewed at our quarterly QA meeting.