VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Inspirit Hilltop Operator LLC
111 Denny Lane
Winchester, VA 22603
(540) 667-5323

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: July 17, 2019

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 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

Technical Assistance:

Discussion occurred on the following topics: 1) Implement system to ensure dietary department is aware of change in diet orders. 2) Implement binder system as survey book. 3) Implementation of forms for audits and reviews as discussed. 4) In-service with staff as it relates to special diets. 5) Quarterly oversight is to include resident files that are reviewed.

Comments:

This monitoring inspection was completed by three LIs on 07/17/2019 as the facility is on a provisional license. There were 62 residents in care. The facility was clean and free from any foul odors. Physician's orders and medication administration records were reviewed for a selected number of residents. Medication carts were inspected and licenses and certifications were reviewed. The activities calendar and menu reflected what the LIs observed. Twelve resident and six staff files were reviewed. Interviews were conducted with residents and staff. There were fifteen violations during this monitoring inspection. Details of non-compliance can be viewed in the violation notice of this report. If you have any questions, please contact the licensing inspector at (540) 332-2330 or e-mail rhonda.whitmer@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-40-A
Description:	Based upon review of the facility medication management plan, the licensee failed to ensure compliance with the facility's own policies and procedures. EVIDENCE: 1) The medication management plan indicates outdated, damaged, and contaminated medications will be checked, identified, returned or destroyed monthly. 2) The medication management plan indicates licensed nursing staff will review the electronic Medication Administration Records (EMARs) on a monthly basis for accuracy, correctness and proper documentation. There shall be no omissions/holes left in the EMARs. 3) The medication management plan indicates licensing nursing staff on a monthly basis, and upon receiving any new orders will check all medications, orders and review EMAR. 4) The medication management plan indicates no medication, diet, medical procedure or treatment shall be started, changed or discontinued without an order from the physician or other prescriber. 5) The medication management plan indicates PRN orders shall include instructions for what to do if symptoms persist. 6) The medication management plan indicates new medication orders and/or refills will be provided within 24 hours. 7) The medication management plan indicates if a medication is not available at the scheduled time of administration, the pharmacy and supervisor will be notified and charting "med not available" on the EMAR alone does not fulfill this requirement. 8) The medication management plan indicates the Resident Wellness Director or designee will monitor medication pass quarterly on medication aides.
Plan of Correction:	Intensive plan of correction required.
Standard #:	22VAC40-73-440-A
Description:	Based upon review of residents' records, the facility failed to ensure the Uniform Assessment Instrument (UAI) is updated at least annually. 1) The UAI for resident A is dated 05/17/2018. 2) The UAI for resident G is dated 05/06/2018. 3) The UAI for resident I is dated 07/15/2018.
Plan of Correction:	Intensive plan of correction required.
Standard #:	22VAC40-73-450-A
Description:	Based upon review of residents' records, the facility failed to ensure a preliminary plan of care is developed on or within seven days prior to admission. EVIDENCE: There is no initial or comprehensive service plan on file for resident H who was admitted 04/01/2019.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	Based upon review of residents' records, the facility failed to ensure all assessed needs are included on the Individual Service Plan. (ISP). EVIDENCE: 1) The Uniform Assessment Instrument (UAI) for resident A is dated 05/17/2018. a. The ISP indicates Resident A receives home health and has been receiving hospice services as of 07/08/2019. Hospice agency, wound care, catheter care and oxygen are not indicated on the ISP. b. Current diet order of finger foods with Boost is not on ISP. 2) The ISP for resident D does not indicate assistance of two direct care staff is required. 3) The UAI for resident K indicates resident can walk and has wandering behavior. The ISP indicates resident is non-ambulatory. 4) The ISP for resident L does not indicate home health services and wound care. a. The UAI for resident L indicates mechanical assistance is needed with bathing. There are no mechanical supports indicated on the ISP. b. The UAI indicates resident L is independent toileting. The ISP indicates assistance is required. c. The ISP indicates finger food and pureed food. has puree and order effective 06/28/19 indicating mechanical soft. d. The ISP for resident L does not indicate home health agency, wound care and oxygen. ISP was printed same day as the inspection. 5) Resident Q has an order for Epi-Pen due to bee allergy. This is not addressed on the ISP. 6) The ISPs do not consistently address ability to use the call bell system.
Plan of Correction:	Intensive plan of correction required.
Standard #:	22VAC40-73-450-F
Description:	Based upon review of residents' records, the facility failed to ensure the Individualized Services Plan (ISP) is updated at least once every 12 months and as needed as the resident changes. EVIDENCE: 1) The ISP for resident E is dated 08/17/2017. 2) The ISP for resident G is dates 06/16/2018 and does not include signature of resident. 3) The ISP for resident I is dated 07/05/2018.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-550-G
Description:	Based upon review of residents' records, the facility failed to ensure an annual review of rights and responsibilities of residents was completed. EVIDENCE: 1) Documentation of review for resident B is 06/23/2018. 2) Documentation of review for resident C is 04/17/2018. 3) Documentation of review for resident D is 11/2016. 4) Documentation of review for resident E is 04/15/2018. 5) Documentation of review for resident G is 04/13/2018. 6) There is no documentation of a review for resident I. 7) Documentation of review for resident J is 05/09/2018. 8) There is no documentation of review for resident L.
Plan of Correction:	Intensive plan of correction required.
Standard #:	22VAC40-73-640-A
Description:	Based upon direct observation, the facility failed to implement a written plan for medication management as it relates to expired medications, storage of medication, and accurate counts of all controlled substances when medication administration staff changes: EVIDENCE: 1) The LI observed a bottle of Lorazepam in the refrigerator in the medication room of the Laurels that expired 01/08/2019. 2) The LI observed a bottle of Lorazepam in the medication cart in the Laurels with a label indicating to keep medication refrigerated. 3) The narcotic inventory count verification sheets for June and July did not consistently include the signatures of staff for the on-coming and off-going shift indicating accurate count of controlled substances.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-650-A
Description:	Based upon review of residents' records, the facility failed to ensure valid orders are on file for resident I. EVIDENCE: Resident C uses a lap belt for trunk support. A physician's order was not on file.
Plan of Correction:	Intensive plan of correction required.
Standard #:	22VAC40-73-680-D
Description:	Based upon review of residents' Medication Administration Records (MARs), the facility failed to ensure medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1) Resident D has the following order: Tramadol HCL 50mg-Take one tablet by mouth every six hours as needed for pain if Acetaminophen is ineffective. a. Documentation in the MAR indicates Tramadol was administered on 07/01/2019 at 2.24pm. There is no documentation Acetaminophen was administered prior to the administration of Tramadol. 2) Resident I has the following order: Check blood pressure every morning. Hold Lasix and Potassium if systolic blood pressure is below 90 and/or diastolic blood pressure is below 60. a. Documentation in the MAR indicates resident's blood pressure was 126/58 on 07/17/2019. Documentation in the MAR indicates Lasix and Potassium were administered on 07/17/2019. 3) Resident R has the following order: Trazodone 50mg-Take one tablet by mouth at bedtime for insomnia. a. Documentation in the MAR indicates medication was not administered on 07/01/19 through 07/08/19 as it was not available. b. The MAR shows duplicate orders for Albuterol. One order indicates to administer every 6 hours as needed for wheezing and shortness of breath and additional order indicates to administer three times daily as needed. 4) Resident S has the following order: Place 2x2 dressing between 4th and 5th toes of the right foot every day to prevent skin breakdown. a. Documentation in the MAR indicates this was not completed on 07/01/19 through 07/14/19 and 07/16/19 through 07/17/19. b. Documentation in the MAR indicates that "hospice does." There is no documentation that hospice completes this daily as ordered. 5) Resident O has the following order: Nitroglycerin 0.2 MG/HR patch-Apply one patch every day for chest pain and remove at night for 10-12 hours. a. Documentation in the MAR indicates medication was not available on 07/01/19. 6) Resident O has the following order: Take one tablet by mouth every week in the morning. Documentation in the MAR indicates medication was not available on 07/06/19 and not administered until 07/13/19.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-K
Description:	Based upon review of residents' medication administration records, the facility failed to ensure PRN orders include all required information. EVIDENCE: The PRN orders for residents D, K, O and T do not consistently include directions as to what to do if symptoms persist.
Plan of Correction:	Intensive plan of correction required.
Standard #:	22VAC40-73-700-1
Description:	Based upon review of resident's medication administration records and the facility failed to ensure orders for oxygen included all required information. EVIDENCE: The Oxygen orders for residents D, I, L, R and S do not identify source as it relates to concentrator or portable tank.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-860-I
Description:	Based upon direct observation, the facility failed to ensure cleaning supplies and other hazardous materials are stored in a locked area. EVIDENCE: 1) During a walk through of the Laurels unit, the door leading to a supply area was observed unlocked and unattended. The area contained cleaning supplies and medical supplies. 2) During a walk through of the facility, a cleaning cart was observed unlocked and unattended in the hallway on the second floor.
Plan of Correction:	Intensive plan of correction required.
Standard #:	22VAC40-73-950-E
Description:	Based upon review of resident and staff records, the facility failed to ensure a semi-annual review of the emergency preparedness and response plan was completed with all staff and residents. EVIDENCE: Documentation of the last review of the emergency preparedness plan was completed on 05/03/2019, but did not include all staff for all shifts and all residents.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-980-A
Description:	Based upon direct observation, the facility failed to have a first aid kit that contained all required items. EVIDENCE: 1) The first aid kit in the east medication room did not include a first aid instruction manual, blanket, tweezers, scissors, thermometer, cold pack, hand sanitizer, disposable bags, flash light with extra batteries and a triangular bandage. 2) The first aid kit in Hawthorne II medication room did not include a flashlight with extra batteries, disposable bags, blanket, first aid manual and a thermometer. 3) The first aid kit in the Hawthorn III medication room did not include a flashlight with extra batteries, thermometer, hand sanitizer, blanket, first aid manual and an ice pack.
Plan of Correction:	Intensive plan of correction required.
Standard #:	22VAC40-73-990-C
Description:	Based upon documentation, the facility failed to ensure at least once every six month, all staff currently on duty for each shift participated in an exercise in which the procedures for resident emergencies are practiced. EVIDENCE: Documentation of the last practice of resident emergencies is 10/23/2018 and did not include all staff on each shift.
Plan of Correction:	Intensive plan of correction required.