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: Nov. 13, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

This inspection is in response to a complaint that was received in the licensing office on 11/13/2019 relating to the allegation of neglect. The information gathered during this complaint investigation supports the allegation, so the complaint is determined to be valid. Please complete the column for "description of action to be taken" and "date to be corrected" for the violations cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. If you have any questions, please contact your licensing inspector at (540) 332-2330.

Violations:

Standard #:	22VAC40-73-1040-A
Complaint related:	Yes
Description:	Based upon communication and documentation, the facility failed to ensure the area to the unit that houses a mixed population was monitored continuously when the facility staff were aware the Wander Guard system was in non-working order. EVIDENCE: 1) Based upon communication, the fire alarm system was being serviced on 11/13/2019 which caused the malfunction of the Wander Guard system. 2) Resident A was able to exit the mixed population area without the staff being aware he was no longer in the building. 3) Resident A was observed outside of the building unsupervised. 3) During the time the Wander Guard system was not working, the facility failed to have continuous monitoring of the entrance and exit to the mixed population unit to ensure residents were not able to exit the area unsupervised.
Plan of Correction:	Resident was assessed for injuries and redirected back to mixed population neighborhood. No injuries were noted. Wander guard door was checked and found to be malfunctioning. Vendor was called immediately to repair wander guard door. 15-minute checks were implemented to ensure resident safety. Care staff monitored door until repair was completed. Resident?s POA was notified. Registered Medication Aide, Maintenance Director or designee will check the following routinely to ensure proper functioning and safety: ? Memory care wander guard doors. ? Mag lock egress doors ? Wander guard bracelets. Registered Medication Aides, Care Managers or designee will check on resident every half hour for one week and then hourly as appropriate. Staff were retrained on elopements and redirection techniques.When outside vendors working in memory care neighborhood, care staff will perform a resident count routinely.