Hillcrest Residential Living, LLC

Based on a review of staff records, the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility shall submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. EVIDENCE: 1. The first day of work for staff #1 was 01/07/2026; the report of TB screening form was dated 01/19/2026. 2. The first day of work for staff #2 was 01/07/2026; the report of TB screening form was dated 01/19/2026.

Based on a tour of the building, the facility failed to ensure that provided their installation or operation has been approved by the state or local building or fire authorities, space heaters may be used only to provide or supplement heat in the event of a power failure or similar emergency. EVIDENCE 1.At the time of inspection on 02/24/2026, two space heaters were being used in the office. There was not a power failure or similar emergency at that time.

Based on a review of resident records, the administrator or designee failed to document that the individual's psychosocial and behavioral history were reviewed and used to help determine the appropriateness of the admission. EVIDENCE: 1. The report of resident physical examination for resident #2, dated 12/29/2025, includes a diagnosis of schizoaffective disorder. 2. The mental health screening determination form contained the name of resident #2, but no other information. 3. There was no documentation in the record for resident #2 indicating the psychosocial and behavioral history were reviewed and used to help determine the appropriateness of the admission.

Based on a review of facility documentation, the facility failed to ensure a semi-annual review is conducted on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. EVIDENCE: 1. The most recently documented six-month review of the emergency preparedness and response plan occurred on 07/24/2024.

Based on observations made during the medication pass, the facility failed to implement its infection control program addressing the surveillance, prevention, and control of disease and infection. EVIDENCE: 1. The facility infection control policy states a barrier must be placed between work surfaces and supply used with blood glucose monitoring. 2. During the 11am blood glucose check for resident #3 on 02/24/2026, staff #2 did not place a barrier on the medication cart before putting the glucometer down on its surface.

Based on a review of resident records, the facility failed to ensure that the comprehensive individualized service plan ( ISP

Based on a review of resident records, the facility failed to ensure acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and to maintain such documentation in the resident's record. EVIDENCE: 1. The record for resident #2 did not contain documentation of orientation to the facility. 2. The record for resident #4 did not contain documentation of orientation to the facility.

Based on a tour of the building, the facility failed to ensure resident bedrooms shall contain all required items. EVIDENCE: 1. Only one operable bed lamp or bedside light was observed in resident room #B4 which accommodates two residents; there was no bedside light for the bed near the door. 2. In resident room #A3 which accommodates two residents, only one operable bed lamp or bedside light was observed; there was no bedside light for the bed near the door.

Based on a tour of the building, the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition. EVIDENCE: 1. The brown chair on the left in the sitting room had five tears in the upholstery, approximately 4 to 5 inches in length. The brown chair in the corner of the same room had several larger tears in the upholstery. 2. In resident room #B7, the blinds on the window nearest to the door appeared to be dusty and the blinds on the window behind the bed were broken in one area, on the right side of the bottom half. In resident room #B5, both sets of blinds were broken on the right sides of the bottom half. In resident room #A10, both sets of blinds were broken on the bottom half. 3. In the bathroom by resident room # A3, the blinds were broken near the bottom, the caulking around the base of the toilet was soiled and stained and the base of the sink under the cabinet doors was scuffed and worn. In the bathroom by resident room #A4, the blinds were broken near the bottom, the caulking around the base of the toilet was soiled and stained and the base of the sink under the cabinet doors was scuffed and worn.

Based on a review of resident records, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section and to maintain documentation of this review which shall include the date of the review in the resident?s record. EVIDENCE: 1. In the record for resident #1, the most recent documentation of resident rights review occurred on 02/01/2023. 2. In the record for resident #2, the most recent documentation of resident rights review occurred on 02/01/2024. 3. In the record for resident #3, the most recent documentation of resident rights review occurred on 05/01/2024. 4. In the record for resident #4, the most recent documentation of resident rights review occurred on 05/01/2024.

Based on a review of resident records, the facility failed to ensure that prior to or at the time of admission to an assisted living facility, all required personal and social information on a person shall be obtained. EVIDENCE: 1. The resident ? personal/social data for resident #3 did not contain the following information: Name, address, and telephone number of all legal representatives, if any; Name, address, and telephone number of the responsible individual stipulated in VAC40-73-550 H, if needed; Known allergies, if any; Previous mental health or intellectual disability services history, if any, and if applicable for care or services; Current behavioral and social functioning including strengths and problems; and any substance abuse history if applicable for care or services. 2. The resident ? personal/social data for resident #4 did not contain the following information: Name, address, and telephone number of all legal representatives, if any; Name, address, and telephone number of the responsible individual stipulated in VAC40-73-550 H, if needed; Known allergies, if any; Previous mental health or intellectual disability services history, if any, and if applicable for care or services; Current behavioral and social functioning including strengths and problems; and any substance abuse history if applicable for care or services.

Based on a review of resident records and interview with staff, the facility failed to ensure the discharge statement contained all required information for one resident. EVIDENCE: 1. (a) The discharge statement for resident #1 did not contain the date on which the resident, his legal representative, or designated contact person was notified of the planned discharge and the name of the legal representative or designated contact person who was notified. 2. (c) The discharge statement for resident #1 did not contain the actions taken by the facility to assist the resident in the discharge and relocation process. 3. The discharge statement for resident #1 was not signed by the licensee or administrator.

Based on a review of resident records, the facility failed to ensure that prior to being placed in charge, the staff member shall be informed of and receive training on his duties and responsibilities and provided written documentation of such duties and responsibilities. EVIDENCE: 1. There was no documentation in the record for staff #3 that she has been informed of and received training on duties and responsibilities prior to being placed in charge.

Based on a tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. EVIDENCE: 1. In resident room #A5, the paint on the walls was peeling in several areas, especially on either side of the closet doors and the wall behind the bed. 2. In resident room #A8, the linoleum was peeling in several small areas. In resident room #A4, the linoleum was peeling in a large area under the bed on the right upon walking into the room. 3. In the bathroom by resident room # A3, the putty on the right of the door frame was soiled and stained.

Based on a review of resident records and interview with staff, the facility failed to ensure the criminal history record report shall be obtained within 30 days of employment for each employee. EVIDENCE: 1. The date of hire for staff #6 was 08/09/2025. 2. At the time of inspection on 09/23/2025, the criminal history record report was not observed in the record for staff #6. 3. According to staff #1, the report had been requested and the required payment cleared the bank account on 09/22/2025, but the report had not yet been received.

Based on a review of facility documentation and interviews with staff, the facility failed to ensure that at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced and to maintain documentation of each exercise. EVIDENCE: 1. The LI did not observe any documentation of staff training related to resident emergencies that had occurred within the past six months. 2. Staff #1 and staff #2 were unable to locate any documentation of staff training related to resident emergencies that had occurred within the past six months.

Based on a tour of the building, the facility failed to provide adequate and accessible closet or wardrobe space for each resident. EVIDENCE: 1. In resident room #A3, there was no accessible closet or wardrobe space for either resident.

Based on a review of resident records, the facility failed to provide written assurance to the resident that the facility has the appropriate license to meet his care needs at the time of admission, and to ensure a copy signed by the resident or his legal representative shall be kept in the resident's record. EVIDENCE: 1. There was no documentation of written assurance observed in the record for resident #2. 2. There was no documentation of written assurance observed in the record for resident #4.

Based on a review of resident records, the facility failed to ensure individualized service plans ( ISP

Based on a review of resident records and staff documentation, the facility failed to ensure medications shall be administered in accordance with the physician's or other prescriber?s instructions. EVIDENCE: 1. On 09/16/2025, staff #5 documented on the medication administration record ( MAR

Based on a review of resident records, the facility failed to ensure that all required personal and social data is maintained on staff and included in the staff record. EVIDENCE: 1. There was no documentation in the record for staff #4 verifying she had received a copy of her current job description. 2. There was no verification of medication aide provisional authorization observed in the record for staff #4.

Based on a review of resident records, the facility failed to ensure individualized service plans ( ISP

Based on a review of resident records, the facility failed to ensure that at the time the medication is administered, the facility shall document on a medication administration record ( MAR

Based on observations made during a tour of the building, the facility failed to ensure space heaters may be used only to provide or supplement heat in the event of a power failure or similar emergency. EVIDENCE: 1. A space heater was observed in each of the offices across from the medication room; they were in operation at the time of inspection. 2. A space heater was observed in the medication room; it was not in operation at the time of inspection. 3. There was not a power failure or similar emergency on the date of inspection.

Based on a review of facility records and interviews with staff, the facility failed to ensure a method of written communication shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. EVIDENCE: 1. According to interview with staff #5, resident #4 broke a window to the ?smoke shack? around mid-October 2024. 2. This incident was not documented in the communication log or in the file for resident #4. 3. The most recent entry in the communication log occurred in July 2024.

Based on a review of staff records and interviews with staff, the facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The date of hire for staff #4 was 06/24/2024. 2. The criminal history record report was not found in the record for staff #4. 3. Staff #5 and staff #2 were not able to locate the criminal history record report for staff #4 in the staff record or elsewhere in the facility.

Based on a review of resident records, the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. EVIDENCE: 1. Physician?s orders for resident #9 signed on 02/17/2025 include the following: Novolog Flexpen Syringe, Inject before meals & at bedtime 151-200=2, 201-250=4, 251-300=6, 301-350=8, 351-400=10, >400=12. Blood sugar checks were not documented on the February 2025 MAR

Based on a review of staff records and interview with staff, the facility failed to ensure a record shall be established for each staff person. EVIDENCE: 1. Per interview with staff #2, staff #3 has worked at the facility on at least three recent occasions and there was no file available at the facility for staff #3. 2. Staff #2 attempted to locate a file for staff #3 but was not able to find it in the facility at the time of inspection.

Based on a review or resident records, the facility failed to ensure medications shall be administered in accordance with the physician's or other prescriber?s instructions. EVIDENCE: 1. The record for resident #10 contains an order dated 02/05/2025 for Amoxicillin 500mg, Dispense: 24, Take 1 cap three times daily (tid) until gone. Staff documented on the February 2025 MAR

Based on a review of facility documentation and interviews with staff, the facility failed to implement its written plan for medication management, including methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The medication management plan for the facility states, ?Medication aides are required to document the administration of all controlled substances in the MAR

Based on a review of staff records and interviews with staff, the facility failed to include and maintain all required personal and social data in the staff record. EVIDENCE: 1. The date of hire for staff #1 was 10/31/2024. Per interview with staff #1 she works in the kitchen, preparing meals for the residents on Mondays, Tuesdays, Thursdays and Fridays. There was no documentation observed in the record for staff #1 or elsewhere in the facility verifying food safety training. 2. Per interview with staff #2, staff #3 has worked at the facility on at least three recent occasions as a Registered Medication Aide (RMA). Verification of current registration as a medication aide for staff #3 was not available at the facility on the date of inspection. 3. Per staff schedules provided to the LI, staff #4 worked as an RMA on 02/01/2025 and 2/02/2025, and was listed as an ?As Needed? ( PRN

Based on a review of facility works schedules, the facility failed to maintain a written work schedule that includes the names and job classifications of all staff working each shift. EVIDENCE: 1. Staff #2 reports staff #3 worked a few evenings during the two weeks prior to inspection on 02/25/2025. 2. Staff #3 was not included on any of the work schedules provided to the LI for the month of February 2025.

Based on a review of resident records, the facility failed to ensure that at the time the medication is administered, the facility shall document on a medication administration record ( MAR

Based on a review of resident records, the facility failed to ensure the Uniform Assessment Instrument ( UAI

Based on a review of resident records, facility documentation and interviews with staff, the facility failed to have staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with this chapter. EVIDENCE: 1. Per the physician?s order sheet signed 02/17/2025 and the February 2025 MAR

Based on observations made during a tour of the building, the facility failed to store medications in a locked area. EVIDENCE: 1. Upon arrival to the facility, the licensing inspector (LI) observed two medication cards for resident #1 in the unlocked office across from the medication room, on the counter by the printer. One card was partially used, the other was unopened. 2. The cards contained the following medications: APAP 500mg, Aspirin EC 81mg, Benztropine 1mg, Docusate SOD 100mg, Famotidine 20mg, Lisinopril 5mg, ? Metformin 500mg, Olanzapine 15mg, Simvastatin 10mg and Trazodone 150mg. 3. Two large black storage totes with yellow lids from the pharmacy were observed in the same unlocked office, full of medication cards containing various medications. 4. Resident #2 was sitting at the desk in this office, and other residents and staff were entering and leaving the office where the medications were not properly stored.

Based on a review of staff records and interviews with staff, the facility failed to obtain required personal and social data to be maintained in the staff record for one employee. EVIDENCE: 1. Staff #2 confirmed during interview on 12/16/2024 that no employee record was established for staff #3. 2. The following personal and social data was not obtained for staff #3: Birth date, current address and telephone number, date employed, verification that the staff person has received a copy of his current job description, an original criminal record report and a sworn disclosure statement, documentation of qualifications for employment related to the staff person's position, including any specified relevant information, name and telephone number of person to contact in an emergency, and documentation of orientation, training, and education required by this chapter, including any specified relevant information.

Based on a review of staff records and interview with staff, the facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. Staff #1 and staff #2 reported during an in-person interview on 12/16/2024 that staff #3 was hired for part time maintenance work approximately ?two to three weeks ago.? 2. Staff #1 confirmed during the in-person interview on 12/16/2024 that a criminal history record report for staff #3 had not yet been requested. 3. Staff #1 resubmitted the completed request for the criminal history record report for staff #3 on 01/16/2025. It was initially submitted on 12/16/2024, but per staff #1, required information was not provided and the request form was returned to the facility.

Based on a review of staff records and interviews with staff, the facility failed to ensure that a record shall be established for each staff person. EVIDENCE: 1. Staff #1 and staff #2 reported during an in-person interview on 12/16/2024 that staff #3 was hired for part time maintenance work approximately ?two to three weeks ago.? 2. Staff #2 confirmed there was no employee record established for staff #3.

Based on a review of staff records, the facility failed to ensure that any person required by this chapter to obtain a criminal history record report shall be ineligible for employment if the report contains convictions of the barrier crimes. EVIDENCE: 1. Staff #1 and staff #2 reported during an in-person interview on 12/16/2024 that staff #3 was hired for part time maintenance work approximately ?two to three weeks ago.? 2. The criminal history record report for staff #3 was requested by staff #1 on 01/16/2025. 3. The criminal history record report for staff #3 was provided to the licensing inspector on 02/10/2025. 4. The criminal history record report for staff #3 contains a conviction for an offense in clause (i) of the barrier crime definition in ? 19.2-392.02 of the Code of Virginia.

Based on a review of staff records and interviews with staff, the facility failed to ensure that health information required by these standards shall be maintained at the facility and be included in the staff record for each staff person. EVIDENCE: 1. Staff #2 confirmed during interview on 12/16/2024 that no employee record was established for staff #3. 2. Within seven days prior to the first day of work at the facility, staff #3 did not submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it.

Based on interview with staff, the facility continued to employ a person who has a conviction of a barrier crime. EVIDENCE: 1. The criminal history record report for staff #3 was provided to the licensing inspector on 02/10/2025. 2. The criminal history record report for staff #3 contains a conviction for an offense in clause (i) of the barrier crime definition in ? 19.2-392.02 of the Code of Virginia. 3. Staff #2 confirmed during an in-person interview on 02/18/2025 that staff #3 is still employed as a part time employee at the facility.