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. 10, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 10:30 am on 1/10/2024 and exited at 11:55 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/28/2023 regarding allegations in the area(s) of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 83 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed 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. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-E
Complaint related:	Yes
Description:	Based upon a review of resident records conducted during a complaint inspection on 1/10/2024, the facility failed to ensure that the individualized service plan (ISP) was signed and dated by the resident or his legal representative for one out of one record reviewed. Evidence: The ISP for Resident 1 (R1), dated 4/24/2023 was not signed by the resident or his legal representative.
Plan of Correction:	Resident Wellness Director/Resident Care Director and or designee will ensure that all residents have a current ISP that is singed by the resident and or their designee. An audit of all ISP?s will be conducted to ensure compliance. Executive Director will provide oversight to ensure compliance.
Standard #:	22VAC40-73-460-F
Complaint related:	Yes
Description:	Based upon a review of records and interview, the facility failed to document in the resident record notification to the next of kin, legal representative, designated contact person, or if applicable, any responsible social agency, of resident fall and failed to include date, time, caller, and person or agency notified. Evidence: 1. According to incident report dated 11/13/2023, family of R1 was not notified by the facility that R1 had fallen and hit his head. 2. According to interview with Staff 1, on 11/13/2023, Blue Ridge Hospice was notified about the fall sustained by R1 and ?Blue Ridge Hospice was to contact the family.?
Plan of Correction:	Resident Wellness Director/Resident Care Director or designee with support of Sage Director will review with all Medications Aides that family notification of incidents is required by the facility not just an outside agency seeing the resident. Emergency calls will come from Hilltop person in charge at the time of the incident and documented. Executive Director will provide oversight to ensure compliance.