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 28, 2022

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 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 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

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 Two licensing inspectors on 07/28/2022 from approximately 9:20am until 4:15pm 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: 76 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Additional Comments/Discussion: Menu and Activity Calendar, Health Care Oversight, Fire Drills, Pharmacy Review, Emergency Preparedness and Response Plan, Resident Council 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

Violations:

Standard #:	22VAC40-73-120-A
Description:	Based on review of staff records, the facility failed to provide documentation of orientation within the first seven working days of employment. EVIDENCE: 1. The orientation and staff record form for staff 10, hired on 02/07/2022 is not completed. 2. The orientation and staff record form for staff 6, hired on 01/24/2022 is not completed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-260-A
Description:	Based on a review of staff records, the facility failed to ensure each direct care staff member maintain current certification in first aid. EVIDENCE: 1. The file for staff 10, hired on 02/07/2022 did not contain documentation of current first aid certification. 2. The file for staff 8, hired on 01/12/2022 did not contain documentation of current first aid certification. 3. The file for staff 6, hired on 01/24/2022 did not contain documentation of current first aid certification.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-490-C
Description:	Based on review of documentation and an interview, the facility failed to ensure the health care oversight included a review of physician?s orders for restraints to determine whether orders are no older than three months as required by 22 VAC 40-73-710 E 2 and an evaluation of whether direct care staff have received the restraint training required by 22 VAC 40-73-270 and whether the facility is meeting the requirements of 22 VAC 40-73-710 regarding the use of restraints. EVIDENCE: 1. Resident 8 has the following order on the Medication Administration Record: Check restraint sheet to make sure it is being signed correctly. Sheet needs signed every half hour, check every half hour. 2. A review of the healthcare oversight that was completed on 04/14/2022 indicates the ?Additional Requirements for Restrained Residents? had not been completed. 3. The LI interviewed staff 11 on 07/28/2022 who confirmed there was no documentation on file indicating the additional requirements for restrained residents was completed during the health care oversight on 04/14/2022.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-620-A
Description:	Based on review of residents? records and an interview, the facility failed to ensure an oversight of special diets is completed every six months by a dietician or nutritionist, for each resident who has such a diet. EVIDENCE: 1. Resident 1 has an order for a pureed diet. 2. Resident 3 has an order for a pureed diet and nectar thickened liquids. 3. Resident 8 has an order for a mechanical soft diet and thin liquids as tolerated. 4. Resident 9 has an order for thickened fluids and chopped foods. 5. The LI interviewed staff 11 who confirmed residents? special diet orders and that an oversight of special diets by a dietician or nutritionist had not been completed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-660-A-1
Description:	Based on direct observation, the facility failed to ensure the medication cabinet, container compartment and storage area that is used for storage of medication and dietary supplements prescribed for residents is locked. EVIDENCE: Based on a walk-though of the facility, the medication cart was observed unlocked and unattended on the second floor.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-680-D
Description:	Based on review of residents? records, the facility failed to ensure medications are administered in accordance with the physician?s orders and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. Resident 6 has the following order: Novolog Flexpen-Inject subcutaneously before meals and at bedtime per sliding scale400 10Units and call NP. 2. Administration Record (MAR) indicates on 07/23/2022 at 9:00pm, resident 6 had a recorded blood glucose of 280 and 2 Units of Novolog was administered instead of 4 Units. 3. Resident 7 has the following order: Glucerna Liquid-Give one can by mouth three times a day with meals for supplement. 4. Documentation in the MAR indicates Glucerna was not available to resident 7 on 07/12/2022 at 5:00pm; 07/13/2022 at 8:00am, 2:00pm and 5:00pm and 07/14/2022 at 8:00am due to ?waiting on delivery from pharmacy? 5. Resident 8 has the following order: Melatonin 3mg-Give one tablet by mouth every evening at bedtime for insomnia. 6. Documentation in the MAR indicates Melatonin was not available to resident 8 on 7/1/2022 ?waiting on delivery from pharmacy; 07/04/2022 ?not available; 07/05/2022, 07/06/2022, 07/08/2022 ?waiting on delivery from pharmacy; 07/09/2022 ?getting from backup?; 07/11/2022 ?not available?; 07/13/2022, 07/14/2022, 07/18/2022, 07/19/2022, 07/20/2022; 07/21/2022 ?waiting on delivery from pharmacy; 07/23/2022, 07/24/2022 ?not available? 7. Documentation in the MAR indicates Melatonin was administered on 07/02/2022, 07/03/2022, 07/07/2022, 07/10/202, 07/12/2022, 07/15/2022 through 07/17/2022 and 07/22/2022. 8. Resident 8 has the following order: Potassium CL Micro Tab 20MEQ ER-Give one tablet by mouth everyday for supplement. 9. Documentation in the MAR indicates Potassium CL was not administered to resident 8 on 07/25/2022 due to ?outside of parameters?; 07/26/2022 and 07/07/2022 ?not available? 10. Resident 8 has the following order: Furosemide 40mg-Give one tablet by mouth every day for fluid/swelling. 11. Documentation in the MAR indicates medication was not administered on 07/25/2022 due to ?outside parameters?
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-90-40-B
Description:	Based upon documentation, the facility failed to ensure criminal record reports (CRR) was completed within 30 days of hire and no more than 90 days prior to hire. EVIDENCE: 1. Staff 1 was hired on 02/21/2022. The Criminal Record Report is dated 05/24/2022. 2. Staff 10 was hired on 02/07/2022. There is no Criminal Record Report on file.
Plan of Correction:	Not available online. Contact Inspector for more information.