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: Jan. 30, 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

Technical Assistance:

1.Consistency in describing mechanical supports needed by individuals on service plan. 2.Reminder that now that everything is caught up you will continue to do sworn disclosures annually for all staff but another background check is not required.

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: 1/30/2023 The Acknowledgement of Inspection form was signed and left at the facility for the date of this inspection. Number of residents present at the facility at the beginning of the inspection: 71 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. No issues were identified. New locking mechanisms have been added to all med room doors. Number of resident records reviewed: 10 TB tests and resident rights were reviewed for all residents. Number of staff records reviewed: 5 All med aide staff licenses were reviewed along with nursing and DCA certificates. TB tests and CPR was also reviewed for all staff as was annual resident rights. All background checks current. Number of interviews conducted with residents: 3 plus 2 families Number of interviews conducted with staff: 2 Observations by licensing inspector: All previous violations resulting in the need for an intensive plan of correction were reviewed and found to be corrected and compliance maintained. This included: medication management updates and training, medication administration monitoring, medication cart checks and storage, medication pass documentation, staff training, personnel files including timely background checks, CPR/First Aid for staff along with other typical renewal items. Additional Comments/Discussion: Fire Inspection 1/20/23 Health Inspection 11/3/2022 All related drills and outside inspections/reviews (dietary, pharmacy, health care oversight) were current. An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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. Should you have any questions, please contact Sharon DeBoever, Licensing Inspector at (540) 292-5930 or by email at sharon.deboever@dss.virginia.gov