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: Sept. 5, 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

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: 09/05/2023, 10:17am to 4:17pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 31 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records, the facility failed to ensure health information required by these standards shall be maintained at the facility and be included in the staff record for each staff person, including subsequent tuberculosis evaluations and reports. EVIDENCE: 1. The date of hire for staff #1 was 05/01/2022. The record for staff #1 did not contain documentation of an annual risk assessment for tuberculosis. The most recent risk assessment form in the record for resident #1 was dated 04/04/2022. 2. The date of hire for staff #2 was 02/01/2022. The record for staff #2 did not contain documentation of an annual risk assessment for tuberculosis. The most recent risk assessment form in the record for resident #2 was dated 04/04/2022.
Plan of Correction:	Staff and resident TB evals will be added to a calendar and email alerts will be sent to notify when due date is approaching. Staff TB evals are scheduled to be conducted on 09/20/2023 by our facility nurse practitioner. Administrator to monitor annually. [SIC]
Standard #:	22VAC40-73-380-A
Description:	Based on a review of resident records, the facility failed to obtain all required personal and social information prior to or at the time of admission for three residents. EVIDENCE: 1. The Personal/Social Data form for resident #2 did not contain information regarding current behavioral and social functioning including strengths and problems. 2. The Personal/Social Data form for resident #3 did not contain the following information: Previous mental health or intellectual disability services history, if any, and if applicable for care and services; current behavioral and social functioning including strengths and problems; and any substance abuse history if applicable for care and services. 3. The Personal/Social Data form for resident #4 did not contain the following information: Previous mental health or intellectual disability services history, if any, and if applicable for care and services; current behavioral and social functioning including strengths and problems; and any substance abuse history if applicable for care and services.
Plan of Correction:	Resident charts will be reviewed quarterly and as needed to ensure required information is available. Administrator to monitor quarterly. [SIC]
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to address all identified needs on the comprehensive Individualized Service Plans (ISPs) for two resident files that were reviewed. EVIDENCE: 1. The Uniform Assessment Instrument (UAI) in the record for resident #1, dated 01/25/2023, identifies mobility, mechanical help only, as a need in which resident #1 requires assistance. The comprehensive ISP in the record for resident #1, dated 02/01/2023, does not address this need. 2. The UAI in the record for resident #2, dated 08/08/2023, identifies walking, mechanical help only, as a need in which resident #2 requires assistance. The comprehensive ISP in the record for resident #2, dated 08/08/2023, does not address this need.
Plan of Correction:	Uniform Assessment Instruments will be reviewed quarterly and as resident needs change to ensure resident needs are reflected on UAI. Administrator to monitor quarterly. [SIC]
Standard #:	22VAC40-73-490-A
Description:	Based on a review of facility documentation and interviews with staff, the facility failed to ensure that for residents who meet the criteria for residential living care the licensed health care professional, practicing within the scope of his profession, shall provide health care oversight at least every six months, or more often if indicated, based on his professional judgment of the seriousness of a resident's needs or the stability of a resident's condition. EVIDENCE: 1. Per facility documentation, the most recent on-site healthcare oversight was provided on 05/18/2022. 2. Per interview with staff #1 and staff #2, on-site healthcare oversight last occurred on 05/18/2022. 3. The facility does not employ a licensed health care professional who is on site on a full-time basis, and thus healthcare oversight should be provided at least every six months.
Plan of Correction:	Healthcare oversights will be reviewed every 6 months. This will be added to a calendar and email alerts will be sent when the due date approaches. Administrator to monitor every 6 months. [SIC]
Standard #:	22VAC40-73-520-I
Description:	Based on observations made during a tour of the building, the facility failed to ensure the current month's activity schedule shall be posted in a conspicuous location in the facility. EVIDENCE: 1. The activity calendar posted in the facility on the date of inspection (09/06/2023) was dated for July 2023.
Plan of Correction:	Activity calendar will be posted in a conspicuous location in the facility for all residents and staff to have access to. Administrator to monitor daily. [SIC]
Standard #:	22VAC40-73-550-G
Description:	Based on a review of staff records, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each staff person, and to maintain evidence of this review via the staff person's written acknowledgment of having been so informed, including the date of the review, in the staff person's record. EVIDENCE: 1. The date of hire for staff #1 was 05/01/2022. The record for staff #1 did not contain acknowledgement of an annual review of residents? rights and responsibilities. The most recent acknowledgement in the record for staff #1 was dated 05/01/2022. 2. The date of hire for staff #2 was 02/01/2022. The record for staff #2 did not contain acknowledgement of an annual review of residents' rights and responsibilities. The most recent acknowledgement in the record for staff #2 was dated 02/01/2022.
Plan of Correction:	Resident rights will be reviewed with staff annually. This will be added to a calendar and email alerts will be sent when the due date approaches. Administrator to monitor annually. [SIC]
Standard #:	22VAC40-73-750-B
Description:	Based on observations made during a tour of the building, the facility failed to ensure each bedroom contains an operable bed lamp or bedside light accessible to each resident. EVIDENCE: 1. Resident rooms B5, A7 and A2 each had two residents assigned to the room, but only one bedside light was observed in each of the rooms. 2. Resident room A5 had one resident assigned to the room and there was no bedside light observed in the room.
Plan of Correction:	A bedside lamp will be provided for each resident in the room. Maintenance to monitor bi-weekly and housekeeping to monitor daily. [SIC]
Standard #:	22VAC40-73-870-B
Description:	Based on observations made during a tour of the building, the facility failed to ensure all buildings shall be well-ventilated and free from foul, stale, and musty odors. EVIDENCE: 1. Resident room A2 had a very strong foul odor present when LI walked into the room. 2. Staff #1 and #2 acknowledged the odor in room A2 is an ongoing issue with one of the residents.
Plan of Correction:	Building and all rooms shall be well ventilated and free from foul, stale, and musty odors. Room A5 will be monitored daily to ensure that it is free from odor. Housekeeping to monitor daily. [SIC]
Standard #:	22VAC40-80-120-E-2
Description:	Based on observations made during a tour of the building, the facility failed to post required documents related to the terms of the license on the premises, including the findings of the most recent inspection of the facility. EVIDENCE: 1. The findings of an inspection that occurred on 04/05/2022 were posted in the facility, however, the most recent inspection occurred on 04/19/2023. 2. Staff #1 confirmed the most recent inspection findings had not been posted in the facility.
Plan of Correction:	Recent inspections will be immediately posted upon receipt. Administrator to monitor monthly. [SIC]