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: Aug. 7, 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 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:

Discussions occurred on the following topics: 1) Ensure residents who have continuous oxygen are monitored for placement of cannula. 2) Contact contracted home health services regarding instruction of cleaning wheelchairs, seats and cushions. 3) One on one activity schedule for residents residing in the Laurels. 4) PT consult recommended for resident A as it relates to positioning. 5) Define "frequent' as it relates to rounds by staff. 6) Monitor all residents for call bell accessibility. 7) Use of other interventions instead of "reminding resident" to utilize call bell as it relates to cognitive impairment. 8) Clarification of diet order for resident H.

Comments:

Two licensing inspectors conducted an unannounced renewal inspection on 08/06/2019. The facility has been on a provisional license due to severity of violations found at the last renewal inspection. At the time of this inspection, there were 62 residents in care. A tour was conducted and the facility was clean and free from any foul odors. Interviews were conducted with residents and staff. Physician's orders and July and August medication administration records were reviewed for a selected number of residents. Thirteen resident and seven staff records were reviewed. The medication variance report was reviewed. There were nine violations during this renewal inspection. The details of non-compliance can be viewed in the violation notice section 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 #:	22VAC40-73-120-A
Description:	Based upon review of staff records, the facility failed to ensure documentation of orientation is on file. The records for staff A, B, C , D, E, F, and G did not contain a complete acknowledgement of orientation and training.
Plan of Correction:	Business Office Manager with the support of Resident Wellness Directors will ensure a current tuberculosis assessment is on file in staff records. Business Office Manager will audit staff records to ensure compliance.
Standard #:	22VAC40-73-200-D
Description:	Based upon review of residents' records, the facility failed to ensure documentation of direct care staff training is on file. EVIDENCE: The records for staff E, F and G did not contain a certificate of completion of direct care staff training.
Plan of Correction:	Business Office Manager with the support of Resident Care Coordinator will ensure documentation of direct care staff training is on file in staff records. Business Office Manager will audit staff records to ensure compliance.
Standard #:	22VAC40-73-250-C
Description:	Based upon review of staff records, the facility failed to ensure a signed job description is on file. EVIDENCE: The records for staff C, D, E, F and G did not contain a signed job description.
Plan of Correction:	Business Office Manager with the support of Resident Care Coordinator will ensure a signed job description is on file in staff records. Business Office Manager will audit staff records to ensure compliance.
Standard #:	22VAC40-73-250-D
Description:	Based upon review of staff records, the facility failed to ensure a current tuberculosis assessment was on file. EVIDENCE: The records for staff E and F did not contain a current tuberculosis risk assessment.
Plan of Correction:	Business Office Manager with the support of Resident Wellness Directors will ensure a current tuberculosis assessment is on file in staff records. Business Office Manager will audit staff records to ensure compliance.
Standard #:	22VAC40-73-450-C
Description:	Based upon review of residents' records, the facility failed to ensure the assessed needs of the resident are included on the Individualized Service Plan (ISP). EVIDENCE: 1) The ISP for resident A did not indicate types of services hospice is providing. 2) The ISP for resident B does not indicate use of oxygen. 3) The file for resident F (admitted 04/01/2019) contained the initial ISP dated 04/02/2019. 4) The ISP for resident G did not indicate use of Hoyer lift, low bed, call bell system and pureed diet with honey thickened liquids. 5) The ISP for resident I did not indicate fall risk. 6) The ISP for resident J did not include thickened liquids and hospice services. 7) The ISP for resident K did not indicate fall risk.
Plan of Correction:	Resident Wellness Directors with the support of Resident Care Coordinator and/or Memory Care Coordinator will ensure that all assessed needs of residents are included in the Individualized Service Plan (ISP). A comprehensive ISP will be completed within 30 days after admission and will include the following: ? Description of identified needs and date identified based upon the UAI, admission physical examination, interview with resident, fall risk rating, if appropriate; assessment of psychological, behavioral, and emotional functioning, and if appropriate, other sources. ?A written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them. ?When and where the services will be provided. ?The expected outcome and time frame for expected outcome. ?Date outcome achieved. An audit of all ISP?s will be completed to ensure compliance. ISP?s will be update accordingly to ensure compliance. Executive Director will provide oversight to ensure compliance.
Standard #:	22VAC40-73-470-A
Description:	Based upon direct observation, the facility failed to ensure the health care service needs of the residents are met. EVIDENCE: During a walk through of the facility, the LI's observed resident L with the lower half of his body hanging out of the bed. The LIs had to search for the call bell, which was located behind resident's dresser. The LIs activated the call bell at approximately 10:05am and again at approximately 10:10am. Multiple staff were observed walking by resident's room. At approximately 10:15, the LIs summoned the director of nursing to assist the resident.
Plan of Correction:	Executive Director or designee with the support of Resident Wellness Director(s), Resident Care Coordinator and/or Memory Care Coordinator will ensure the health care service needs of the residents are met. Resident Wellness Director(s), Resident Care Coordinator and/or Memory Care Coordinator will retrain direct care staff to include but not limited to the following areas: Ensure that nursing call bell/system is within eyesight and reach of residents. Responding to the nursing call system in a timely manner. Executive Director will monitor to ensure compliance.
Standard #:	22VAC40-73-550-G
Description:	Based upon review of staff records, the facility failed to ensure a written acknowledgment of review of resident's rights is on file. EVIDENCE: The records for staff B, D, E and G did not contain a signed and dated written acknowledgment of review of resident's rights.
Plan of Correction:	Business Office Manager or designee will ensure an annual review of rights and responsibilities of residents are completed. Executive Director will provide oversight to ensure compliance.
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 C has the following order: Esomeprazole MAG DR 40mg-Take 1 capsule by mouth every morning before breakfast. a. Documentation in the MAR indicates resident received medication on 08/01/19 and 08/03/19 at 6:00am and 7:00am. b. Documentation in the MAR indicates resident had multiple refusals of medication in July and August. There is no documentation of physician notification in the MAR. 2) Resident O has the following order starting on 07/19/19: Olopatadine HCL 0.2% eye drop: Instill one drop into each eye twice daily for 7 days. a. Documentation in the MAR indicates medication was administered on 07/19/19 through 07/31/19 and on 08/01/19 at 9:00pm, 08/05/19 at 9:00am and 9:00pm. 3) Resident O 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 08/01/19 through 08/06/19. Documentation indicates "hospice does." There is no documentation of hospice completing.
Plan of Correction:	Resident Wellness Directors will ensure that 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. Resident Wellness Directors will provide frequent/routine oversight to ensure compliance. Resident Wellness Directors will retrain all Registered Medication Aides on facility?s medication management policy.
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 memory neighborhood, a door to the supply room with a keypad lock was observed open and unattended. A cleaning cart with cleaning supplies was observed inside the room.
Plan of Correction:	Director of Housekeeping with the support of Maintenance Coordinator will ensure cleaning supplies and other hazardous materials are stored in a locked area. Housekeeping carts will have a secure storage area for cleaning supplies and other hazardous materials or will be within arms-length of housekeeping staff at all times.