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. 10, 2023

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 inspector was on-site at the facility for each day of the inspection: 10/10/2023 9:00AM until 2:45PM 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: 96 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: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: morning medication pass, noon-time meal, activities 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 #:	22VAC40-73-300-B
Description:	Based on document review, resident record review, and staff interview, the facility failed to ensure a method of written communication shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. EVIDENCE: 1. The licensing inspector (LI) received an incident report from staff person 6 via email on 08/10/2023 that resident 9 had an unreported fall that occurred on 08/06/2023 around 6:00PM and that the resident had been sent out to the hospital on 08/06/2023. The resident had been sent out to the hospital on 08/06/2023 due to chest pains and returned to the facility on 08/07/2023 with a left wrist fracture. On 08/09/2023 the resident voiced complaints of chest pain again, was sent out to the hospital on 08/09/2023 and returned to the facility with a diagnosis of a sternal fracture. 2. Interview with staff person 6 on 10/10/2023 revealed that staff person 4 did not document on the facility?s communication log to inform direct care staff on all shifts that the resident had fallen on 08/06/2023 and that the fall was not reported by staff person 4 to the Resident Care Director until 08/10/2023 which was also indicated in the incident report submitted to the LI by staff person 6 on 08/10/2023.
Plan of Correction:	Immediate Corrective Action: The RMA was re-educated on 8/10/23 regarding completing an Incident Tracker timely and adding resident changes to the communication log prior to the end of their shift. A corrective action was issued to this RMA on 8/10/23. Additional Corrective Action: All staff have been in-serviced on 10/12/23 by the Executive Director on following the procedures to ensure there is written communication on changes in the resident?s condition, injuries, and/or complaints so all shifts can be informed. Ongoing: The Executive Director and/or the Resident Care Director will review the communication logs daily for changes in residents and will ensure the care staff are aware of such changes. The Executive Director will review compliance in communication during our quarterly QA meeting for compliance.
Standard #:	22VAC40-73-660-B
Description:	Based on observations of the physical plant, resident record review and resident interview, the facility failed to ensure that the medications kept in resident?s rooms were stored in an out of sight location in the resident?s room and only for residents who have been assessed as capable of self-administering their own medications. EVIDENCE: 1. The Uniform Assessment Instrument (UAI) in the record for resident 3, dated 05/13/2023, indicates that medication should be administered/monitored by lay person specifically an RMA or Nurse and that the resident is orientated. 2. During on-site inspection on 10/10/2023 at approximately 9:46AM, two Licensing Inspectors (LIs) observed a bottle of Aleve (Naproxen Sodium 220mg), Allergy Medicine (Diphenhydramine 25mg) and One A Day Men?s 50 Plus Vitamins located in resident 3?s bathroom on a shelf near the sink. During an interview with the two LIs and resident 3, resident 3 noted that they take the medications noted in their bathroom on their own when they feel it is necessary. The resident?s record contains no physician?s orders for the aforementioned medications for resident 3 to be able to self-administer them and the resident is not capable of self ? administering medications according to his UAI.
Plan of Correction:	Immediate Corrective Action: The Resident Care Director spoke with the resident regarding keeping medications in his room. All the medications were removed from the resident?s bathroom on 10/10/23 until the MD could assess the resident on 10/11/23. Additional Corrective action: This resident was assessed on 10/11/23 by the facility MD to approve the resident to self-administer as needed medications. Upon the assessment, an order was obtained for this resident to self-administer as needed medications in his room. The UAI and ISP were updated on 10/11/23 to reflect these changes. Ongoing: The Resident Care Director and/or the Resident Care Coordinator will complete a weekly random room search for medications observed in resident?s rooms without a MD order or a completed self-administration assessment tool. The Executive Director will review the results of these audits during our quarterly QA meeting for compliance.
Standard #:	22VAC40-73-680-D
Description:	Based on observation during medication pass, staff and resident interviews and resident record review, the facility failed to ensure that medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 10 contains signed physician?s orders, dated 09/08/2023, for NovoLog FlexPlen 100 units: 4 units subcutaneous with 1 extra unit for every 50 above 150, 15 minutes prior to meals. The October 2023 medication administration record (MAR) contains documentation that staff administered 0.01 units of Novolog 100 Unit Flexpen on 10/02/2023 at 4:45PM, administered 0 units on 10/03/2023 at 4:45PM, administered 0 units on 10/04/2023 at 11:45AM, and administered 0 units on 10/09/2023 at 4:45PM. Resident 10?s October 2023 MAR contains documentation from staff on 10/03/2023 stating ?Held per parameters? and 10/04/2023 stating ?held per physician?s orders?. The October 2023 MAR for resident 10 indicates Novolog was not administered on four occasions as prescribed. 2. The record for resident 12 contains signed physician?s order, dated 09/02/2023, for Hydralazine 25MG take one tablet by mouth once daily in the afternoon for HTN and to hold the medication if the resident?s blood pressure is less than 180/100. The October 2023 MAR for resident 12 contains documentation that the resident was administered Hydralazine 25MG daily at 5:00PM from 10/01/2023 through 10/09/2023; however, the documented blood pressure readings by staff on the October 2023 MAR are all less than 180/100 daily at 5:00PM from 10/01/2023 through 10/09/2023. 3. The record for resident 13 contains signed physician?s orders, dated 07/06/2023, which indicate that the resident?s Seroquel should be crushed into food when administered. The October 2023 MAR for resident 13 indicates that for his Quetiapine Fumarate 50 MG TAB (Seroquel) medication staff should crush 1 tablet, mix with food, and give by mouth twice a day. On the date of inspection at approximately 9:10AM, one licensing inspector (LI) observed staff person 4 remove the Quetiapine Fumarate 50 MG TAB from its card and place it into a medication cup with his other morning medication. Prior to staff person 4 taking the resident?s medication to his room, this LI indicated to staff person 4 that his Quetiapine Fumarate 50 MG TAB medication card and current MAR indicate to crush his tablet and give with food. Staff person 4 reviewed the current MAR and stated to the LI that they don?t normally crush his Quetiapine Fumarate 50 MG tablet and mix it with food because he can swallow it without it being crushed. The October 2023 MAR for resident 13 indicates that the resident was administered their Quetiapine Fumarate daily until the date of inspection.
Plan of Correction:	Immediate Corrective Actions: RMA #4 was re-educated on 10/10/23 in following the physician orders during the medication pass. This med aide adjusted in crushing the medication prior to administering as prescribed on 10/10/23 with the Licensing Inspector present. RMA #5 was re-educated on 10/10/23 by the Resident Care Director in following the parameters within the medication order for blood pressure readings. RMA #5 was re-educated on 10/10/23 by the Resident Care Director in following the parameters within the medication order for administering Humalog Insulin Sliding Scale. Additional Corrective Actions: The facility MD reviewed the residents? medications list and updated the instructions on the parameter orders for insulin and blood pressure for better clarity during medication administration. A review of residents that did not require crushed medications were reviewed and updated on 10/11/23. All medication aides will be in-serviced on 10/26/23 by the Resident Care Director regarding proper medication administration. Ongoing: The Resident Care Director and/or Wellness Nurse will review new orders regarding medications that require parameters and they will confirm specific instructions are documented prior to the medication aides administering. The medication aide will alert the Resident Care Director or the Wellness Nurse when medications are held when the readings are outside the set parameters. Weekly medication cart audits will be completed by the Resident Care Director or Resident Care Coordinator to ensure the medication aides are following the MD orders as prescribed. The Executive Director and Resident Care Director will use monthly audits to measure compliance and the results will be reviewed during our quarterly QA meeting.