VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Inspirit Hilltop Operator LLC
111 Denny Lane
Winchester, VA 22603
(540) 667-5323

Current Inspector: Jill James (540) 418-2631

Inspection Date: Dec. 31, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES

Comments:

This inspection is in response to a complaint that was received in the licensing office on 12/26/19 relating to the allegation of the facility failing to follow their policies and procedures. The information gathered during this investigation supports the allegation, so the complaint is determined to be valid. 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 email rhonda.whitmer@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-40-A
Complaint related:	Yes
Description:	Based upon review of facility's monitoring policy for the mag lock egress doors of the mixed population neighborhood, the licensee failed to implement and document door checks two times per shift. EVIDENCE: 1) The facility policy indicates that all doors in the mixed population neighborhood will be checked and documented two times per shift; beginning of shift and mid shift. a. The log for 11/14/19 is not complete for 7:00am, 11:00am and 3:00pm. b. The log for 11/15/19 is not complete for 7:00pm. c. The log for 11/16/19 is not complete for 3:00pm. d. The log for 11/17/19 is not complete for 7:00pm. e. The log for 11/19/19 is not complete for 7:00am, 11:00am, 11:00pm and 3:00am. f. The log for 11/20/19 is not complete for 7:00am, 11:00am, 11:00pm and 3:00am. g. The log for 11/21/19 is completely blank for all shifts. h. The log for 11/22/19 is not complete for 7:00am, 11:00am, 11:00pm and 3:00am. i. The log for 11/23/19 is completely blank for all shifts. j. The log for 11/24/19 is not complete for 7:00am, 11:00am, 11:00pm and 3:00am. k. The logs for 11/25/19 and 11/26/19 are not complete for 3:00am. l. The log for 11/27/19 is not complete for 7:00am, 11:00am, 11:00pm and 3:00am. j. The log for 11/28/19 is not complete for 3:00am. k. The log for 11/29/19 is not complete for 11:00pm and 3:00am. l. The log for 11/30/19 is not complete for 3:00am. m. The logs for 12/2/19 and 12/3/19 are not complete for 11:00pm and 3:00am. n. The logs for 12/4/19, 12/5/19 and 12/6/19 are not complete for 11:00pm and 3:00am. o. The log for 12/7/19 is not complete for 7:00am, 11:00am, 3:00pm and 3:00am. p. The log for 12/8/19 is completely blank for all shifts. q. The log for 12/9/19 is not complete for 11:00am, 11:00pm and 3:00am. r. The log for 12/10/19 is not complete for 11:00pm and 3:00am. s.The log for 12/11/19 is completely blank for all shifts. t. The log for 12/13/19 is not complete for 11:00pm and 3:00am. u. The log for 12/16/19 is not complete for 7:00am, 11:00am, 11:00pm and 3:00am. v. The log for 12/17/19 is not compete for 7:00am and 11:00am. w. The log for 12/18/19 is not complete for 11:00am, 3:00pm and 3:00am. x. There are no logs for 12/19/19 through 12/23/19. y. The logs for 12/24/19 and 12/25/19 are not complete for 3:00pm, 7:00pm, 11:00pm and 3:00am.
Plan of Correction:	Registered Medication Aide, Care staff, Maintenance Coordinator or designee will check the following twice a shift to ensure proper functioning and safety: ? Memory wander guard doors. ? Mag-lock egress doors. Resident Wellness Director or designee will check the following weekly to ensure proper functioning and safety: ? Resident wander guard bracelets. Executive Director or designee will provide routine oversight to ensure compliance. All checks have been documented and in compliance since 12/26/19. On 01/10/20 Corner Stone Security Experts performed a complete review on all memory care doors for proper functioning. On 01/17/20 the Executive Director has ordered new mag-locks with new transformers and battery backups for all memory care unit doors. New mag-locks will be delivered and installed on 01/27/20. Also, a new audible alarm on memory care door #2 has been installed. At this time, designated staff will continue to document checks on all memory care doors twice a shift to include weekly documented checks on wander guards.