VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hillside Residential Living
403 N. Coalter Street
Staunton, VA 24401
(540) 885-0191

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Oct. 6, 2023 and Oct. 16, 2023

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 11:40 am on 10/6/2023 and exited at 12:30pm. LI entered the facility at 3:20 pm on 10/16/2023 and exited at 4:10 pm. 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 8/31/2023 regarding allegations in the area(s) of resident care and related services. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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 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. 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 #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based upon record review during a complaint inspection on 10/6/2023 and 10/16/2023, the facility failed to ensure that the Medication Administration Record (MAR) included the initials of direct care staff administering the medication and any medication errors or omissions for one out of one resident. Evidence: 1. The initials of the direct care staff who administered medications at 4 pm and 8 pm on 8/23/2023 to Resident 1 (R1) were missing on the MAR and there was no documentation of medication omissions. 2. The initials of the direct care staff who administered medications at 8 am, 4 pm, and 8 pm on 9/7/2023 to R1 were missing on the MAR and there was no documentation of medication omissions. 3. The initials of the direct care staff who administered medications at 8 am, 11 am, 4 pm, and 8 pm on 9/10/2023, 9/18/2023, and 9/23/2023 to R1 were missing on the MAR and there was no documentation of medication omissions. 4. The initials of the direct care staff who administered medications at 11 am, 4 pm, and 8 pm on 9/30/2023 were missing on the MAR and there was no documentation of medication omissions.
Plan of Correction:	RMAs received a two-hour training by administrator on signing off MARS in a timely manner and a weekly MAR audit will be done on a random resident.