VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hillcrest Residential Living, LLC
27468 Overbrook Dr.
Meadowview, VA 24361
(276) 944-3150

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: Oct. 4, 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

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: 10/04/2022 10:15am-2:40pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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. 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 Crystal B. Mullins, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on review of resident records, the facility failed to include all required information on a physical examination within 30 days preceding admission for one resident. EVIDENCE: 1. Resident # 2 had a physical exam dated 08/23/2022. Allergies listed were: penicillins and red dye. There were no reactions listed.
Plan of Correction:	Allergies listed on physicals will have reactions to each one. Corrected 10/05/2022 Administrator/Designee to monitor. [sic]
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to include all identified needs listed on the Uniform Assessment Instrument (UAI) on the comprehensive Individualized Service Plan (ISP) for one resident. EVIDENCE: 1. Resident # 1 has a UAI completed on 07/20/2022; walking, toileting, and bathing with mechanical help only was identified. These identified needs were not listed on the ISP completed on 09/09/2022 for this resident. 2. Resident #3?s UAI was completed on 05/10/2022; walking with assistance was identified. The ISP completed on 05/10/2022 did not identify this as a need for this resident.
Plan of Correction:	All ISP?s will reflect residents? needs addressed in UAI. Corrected 10/05/2022 Administrator/Designee to monitor. [sic]
Standard #:	22VAC40-73-520-I
Description:	Based on observations made during the tour of the building, the facility failed to post the current month?s activity schedule. EVIDENCE: 1. When LI toured the facility on 10/04/2022 an activities calendar for September 2022 was posted.
Plan of Correction:	Activity calendar will be posted at the end of each month for the following month. Corrected 10/04/2022 Licensee/Administrator/Designee to monitor [sic]
Standard #:	22VAC40-73-640-A
Description:	Based on observations during the medication cart audit and the noon medication pass, the facility failed to adhere and implement their medication management plan when counting controlled substances when assigned medication administration staff changes. EVIDENCE: 1. The facility?s policy for narcotic count at shift change requires two registered medication aide?s sign off on the controlled substance count sheet. This was not done consistently from 09/15/2022-10/04/2022.
Plan of Correction:	Narcotics will be counted, and each total will be initialed by both medication aides at each shift change between medication aides. Corrected 10/05/2022 Administrator/Designee to monitor [sic]
Standard #:	22VAC40-73-680-D
Description:	Based on observations made during the noon medication pass and the medication cart audit, the facility failed to administer medications consistent with the standards of practice outlined in the medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. Resident #4 is prescribed Fluticasone prop 50mg spray, Inhale two sprays in each nostril at bedtime. This medication did not contain an open date but had been opened and used.
Plan of Correction:	ll nasal sprays, eye drops, etc. will have open dates listed on container when opened. Corrected 10/05/2022 Administrator/Designee to monitor [sic]
Standard #:	22VAC40-73-680-M
Description:	Based on observations made during the noon medication pass and the audit of the medication cart, the facility failed to have medications ordered for PRN (as needed) administration available in the facility for the resident. EVIDENCE: 1. Resident #5 is prescribed Ibuprofen 100mg/5mL, take 2.5 mL by mouth every eight hours as needed. This medication was not available for this resident.
Plan of Correction:	PRN medication inventory will be performed weekly to ensure all ordered medications are always available. Corrected 10/04/2022 Administrator/Designee to monitor [sic]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during the tour of the building, the facility failed to maintain the interior of the building in good repair and clean. EVIDNECE: 1. The restroom across from Room A5 had a liquid substance on the floor between the commode area and the sink area.
Plan of Correction:	Bathroom will be monitored daily to monitor for cleanliness and safety. Corrected 10/04/2022 Floor Supervisor/Designee to monitor. [sic]