Virginia DSS · Assisted Living Facility

Hickory Hill Retirement Community

📍 900 Cary Shop Road, Burkeville, VA, 23922

ID 21886Two Year licenseActive
17
Inspections
On record
7
With violations
Visits that cited something
10
Clean visits
Nothing cited
26
Violations cited
Individual findings
21
Standards cited
Distinct rules
8
Complaint visits
Prompted by a complaint

Hickory Hill Retirement Community was inspected 17 times between July 1, 2020 and January 23, 2025 by the Virginia Department of Social Services. 7 of those visits ended with violations cited and 10 with none. Across that history VDSS cited 26 violations under 21 distinct standards. 8 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 15 of these 17 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
01/30/2027
Administrator
Laura Glasscock
Licensing inspector
Coy Stevenson
Inspector phone
(804) 972-4700
Approved for
Non-Ambulatory · Special Care Unit · Assisted Living

Inspection History

17

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

January 23, 2025Complaint survey0 violations
Inspection dates
01/23/2025
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
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: This licensing inspector was on-site at the facility on January 23, 2025 from approximately 11:00 AM to 11:30 AM. A complaint was received by VDSS Division of Licensing on January 13, 2025, regarding allegations in the area(s) of: maintenance of buildings and grounds Number of residents present at the facility at the beginning of the inspection: N/A The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: N/A Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: The resident’s room in question was inspected. All the furniture and resident’s belongings were removed. The resident was moved to a new room while extermination protocols and procedures are being following to eradicate the infestation. This licensing inspector was informed that the carpet is being replaced as part of the sanitation process. Additional Comments/Discussion: N/A The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 3, 2024Inspection1 violation
Inspection dates
12/03/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
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: The licensing inspector was on-site from approximately 11:00 AM – 3:00 PM 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: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 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 Coy Stevenson, Licensing Inspector at 804-972-4700 or by email at coy.stevenson@dss.virginia.gov
Violations
22VAC40-73-120-A
Based on record reviews and interviews, it was determined that the facility did not ensure that new employees complete orientation training required by 22VAC40-73-120.B and 22VAC40-73-120.C within the first seven working days of employment.
Evidence
  1. A review of the record for staff #3 did not contain documentation showing staff #3 was trained on the topics required by 22VAC40-73-120.B and 22VAC40-73-120.C. Staff #3 was hired on September 19, 2024.
  2. Employee #4 confirmed that documentation showing staff #3 was trained on the topics required by 22VAC40-73-120.B and 22VAC40-73-120.C was not in the record for staff #3.
Plan of correction
Not published by VDSS.
December 3, 2024Complaint survey0 violations
Inspection dates
12/03/2024
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
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: A complaint was received by VDSS Division of Licensing on November 25, 2024, regarding allegations in the area(s) of: resident care and unsanitary conditions in the facility On December 03, 2024, the licensing inspector met with the administrator of the facility. A review of how residents are monitored to ensure skin break-down does not occur when residents are incontinent and unable to care for themselves was reviewed. Infection control procedures were also discussed that address preventing infestations. During the on-site inspection, inspections of communal areas and randomly selected resident rooms was completed. Observations of residents interacting with each other and with staff also occurred. It was also noted from visitor logs and observations by the licensing inspector, that visitors and other community members frequent the facility. No health or safety concerns were noted. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Coy Stevenson, Licensing Inspector at 804-972-4700 or by email at
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 19, 2024Complaint survey0 violations
Inspection dates
11/19/2024
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
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: The licensing inspector was on-site on 11/19/24. 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 10/07/24, regarding allegations in the area(s) of: staff substance abuse while at the facility; verbal and physical abuse of residents; resident neglect Number of interviews conducted with staff: 1 Additional Comments/Discussion: An interview was conducted with the facility administrator. During the interview, the administrator denied the allegation that staff use or attempt to obtain illicit substances while at the facility. The administrator stated that there have been no reports from either staff or residents expressing such concerns. There have also not been any instances where a staff member was suspected of being under the influence. The administrator stated during the interview that there have not been any reports from staff or residents expressing concern over the number of staff on duty. Additionally, the administrator stated there have been no reports by staff or employees related to concerns of physical/verbal abuse by staff, nor have there been any reports or concerns related to residents care needs being neglected. The administrator discussed in detail a resident who requires ostomy care, who frequently pulls the tubes out, resulting in these tubes being secured more frequently than would otherwise be needed. This increase in attaching/securing the tubes, results in increased skin irritation. The administrator noted that efforts to reduce the frequency the resident removes, or attempts to removes these tubes, include increased monitoring and attempting to prevent the resident from isolating in their room. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 17, 2024Complaint survey0 violations
Inspection dates
04/17/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
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: On April 17, 2024, Licensing inspectors met with the administrator of the facility. The inspection began at approximately 10:00 AM and was concluded at approximately 10:25 AM. The administrator was informed that a complaint had been submitted to the Department, which required an onsite inspection. The administrator was given the names of each client alleged to be held hostage at the facility. The administrator stated that everyone identified as a resident/hostage in the complaint is not a current resident, nor have they ever been a resident. The administrator was given the names of each employee who is alleged to be involved in keeping the alleged residents hostage. The administrator again stated that each person identified as an employee in the complaint is not and has never been an employee of the facility. 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 April 10, 2024, regarding allegations in the area(s) of: Residents’ freedom of movement is being restricted. Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Upon arrival, a resident was observed walking around in the front of the facility. Upon entry to the facility, several residents were observed moving about the facility unfettered. Upon exiting the facility, two residents were observed sitting on chairs provided by the facility. The facility was in good repair and the grounds were maintained in a safe condition. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Coy Stevenson, Licensing Inspector at 804-972-4700 or by email at coy.stevenson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 6, 2023Inspection0 violations
Inspection dates
12/06/2023
Technical assistance
Care plan details
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: 10/18/2023, 10:25am – 1:30pm 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: 62 An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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 Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 18, 2023Complaint survey0 violations
Inspection dates
10/18/2023
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: 10/18/2023, 10:15 – 11am 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 8/22/2023 regarding allegations in the areas of: Resident Care and Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 60 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 14, 2023Inspection3 violations
Inspection dates
03/14/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3-14-2023; 10:30 – 11:20 am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 2-27-2023 regarding allegations in the areas of: Personnel, Resident Care Number of residents present at the facility at the beginning of the inspection: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds, staff interviews, resident record, staff record. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-73-40-A
Based on record review, the facility failed to ensure compliance with the facility’s own policies and procedures.
Evidence
  1. The facility’s Abuse and Neglect Prevention Policy dated 5-10-2020 documents sexual abuse as: “Sexual abuse: Contact or activity of a sexual nature between a staff member and a resident”
  2. Resident #1 admitted 2-17-2023. A self-reported incident received by the facility from Staff #1 on 2-27-2023 documented that Resident #1, who resides in the safe, secure environment (SSE) of the facility, was observed with Staff #3, who was performing oral sex on Resident #1. 3.Staff #2’s statement to the licensing inspector during interview was that at approximately 4:20 a.m. on 2-26-2023, Staff #2 was going to get washcloths from the Assisted Living side of the community outside of the SSE when he heard a noise from Resident #1’s room. Upon entering Resident #1’s room, Staff #2 observed Staff #3 engaging in oral sex on Resident #1.
  3. Video footage reviewed with Staff #4 showed Staff #2 walking past Resident #1’s room at the time he confirmed he had left Resident #1’s room after witnessing the incident between Resident #1 and Staff #3. Staff #2 left and proceeded to report the incident to the staff in charge (Staff #1 via call).
Plan of correction
Not published by VDSS.
22VAC40-73-110-1
Based on record review and interview with staff, the facility failed to ensure staff were considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled.
Evidence
  1. Resident #1 admitted 2-17-2023 and was reported as “alert and oriented x2” per the Report of Resident Physical Examination dated 2-14-2023. Per verbal interview with Staff #1 during inspection, Resident #1 is “appropriate for special care due to his confusion.”
  2. Resident Notes dated 2-27-2023 by Staff #1 documented, “Late entry: On the morning of 2-26-23, I received a call from [Staff #2]. [Staff #2] was going to other wing to pick up wash clothes for get ups and was looking for other staff to alert that he would be off of the wing for a minute. When he proceeded to go down the hallway, this resident’s [Resident #1] door was closed and he heard moaning coming from within. [Staff #1] cracked the door opened to find [contract staff], [Staff #3], on [Staff #3’s] knees beside [Resident #1]’s bed and [Staff #3] was performing oral sex on [Resident #1]…. [At a later time, resident #1 was interviewed and...] [Resident #1] was asked if any staff member had ever performed any sexual acts that made [Resident #1] uncomfortable and [Resident #1] repeated the same scenario as documented above. Stating that "a [descriptor of Staff #3] came into my room and was washing me up and my penis became hard and the [descriptor of Staff #3] sucked my dick". I asked [Resident #1 if he tried to stop [Staff #3] in any way and [Resident #1] response was "No, because I was scared."…”
  3. Staff #4 confirmed during interview that Staff #3 engaged in a sexual act with Resident #1 at the facility on 2-26-2023 that was not respectful of the rights of persons who are aged and disabled. Staff #4 confirmed at that time of inspection that Staff #3 was not allowed to return to the facility following this shift.
Plan of correction
Not published by VDSS.
22VAC40-73-320-A
Based on record review, the facility failed to ensure that the physical examination preceding admission contained a description of the person’s reactions to known allergies.
Evidence
  1. Resident #1’s “Report of Resident Physical Examination” dated 2-14-2023 documented allergies of “Barium Sulfate, Codeine, Ezetimile, and grass pollen”; however, no allergic reactions were documented for the aforementioned allergies.
Plan of correction
Corrected by health oversight nurse.
January 12, 2023Inspection2 violations
Inspection dates
01/12/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 1-12-2023, 7:20 a.m. – 12:15 p.m. 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: 68 Number of resident records reviewed: 8 Number of staff records reviewed:3 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 3 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 Alexandra Poulter, Licensing Inspector at (804) 662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on record review and interview, the facility failed to ensure the facility reported to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. Two “Resident Documentation Form” forms located in Resident #4’s record documented the following: a. 11/16/2022: “Resident [#4] refused to take her meds… threw cup of water at [Resident #9. [Resident #4] jumped up and attacked [Resident #9] …. Kicked [Staff #6] and [Resident #9]. (Note by Staff #6). b. 11/17/2022: “[Resident #4] had an altercation with [Resident #4’s] roommate last night. It was reported to day shift that [Resident #4] kicked [Resident #9] in the face…” (Note by Staff #3).
  2. Neither incident involving Resident #4 and Resident #9 from 11-16-2022 and 11-17-2022 was reported to the regional licensing office.
Plan of correction
Staff #2 was retrained by staff #1 on this standard and the different circumstances that constitute a need for a report to our LI, not just a fall, elopement or trip to the emergency room. Staff #2 will be retraining her Shift Leaders and RMA’s on this same information at the 2/10 nursing staff meeting, for times when they are the DSIC to ensure there are no future violations of this nature.
22VAC40-73-450-F
Based on record review and interview with staff, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated as needed for a significant change of a resident’s condition.
Evidence
  1. Resident #6 admitted 3-05-2019. Resident #6’s home health skilled nursing services began 9-27-2022 and continued through 1-10-2023 per the “Agency Weekly Communication Sheet”; however, these services were not identified on the resident’s ISP dated 3-01-2022.
  2. Staff #2 acknowledged during interview that Resident #1 and Resident #6’s ISPs were not updated with appropriate information.
Plan of correction
Staff #1 and staff #2 discussed this violation and examined the current process up updating ISP’s when information changes or services are added for our residents to ensure they are not overlooked. Staff #2 generally does an excellent job of keeping the care plans accurate and up to date, but she will be more diligent when it comes to adding home health services.
September 14, 2022Inspection4 violations
Inspection dates
09/14/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISIONx22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTSx22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESSx22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Technical assistance
Elopement policy specifications regarding resident scenarios
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9-14-2022, 10:00 – 11:00 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 9-14-2022 regarding allegations in the area of resident care and related services: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov.
Violations
22VAC40-73-460-D
Based on record review and interview with staff, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering from the premises.
Evidence
  1. A self-reported incident was received from the facility on 8-23-2022 regarding an incident on 8-19-2022 involving Resident #1. The report documented, “Resident [#1] eloped and was unaccounted for for approximately 2 hours. Resident [#1] was located by staff in the woods behind facility…”
  2. Documentation in the record of Resident #1 contains a “Report of Resident Physical Examination” dated 7-18-2022. The resident’s “General physical condition including systems review” is documented as, “Advanced dementia with confusion – medically stable otherwise”.
  3. Staff #1 confirmed during onsite inspection on 9-14-2022 that Resident #1 was located emerging from the woods behind the facility and that the resident was unsupervised during that period of elopement.
Plan of correction
Following the elopement, an After-Action meeting was held to investigate and discuss what circumstances allowed the incident to happen. While Resident #1 had not been identified by her physician or family prior to admission as an elopement or wandering risk, she did have advanced dementia and therefore, should have been watched more closely than she was by the staff member assigned to her care. The After-Action meeting determined that 1) The nursing assistant assigned to this resident failed to ensure her whereabouts for 45 minutes 2) The maintenance assistant failed to secure the exterior gate of the courtyard after driving through with the lawnmower. The facility has updated its procedure for all new residents, regardless of cognitive status – that they shall not only be treated as a wandering risk for the first two weeks, but that 1) the nurse assigned shall document the resident’s exact location in the electronic chart every 20 minutes and 2) immediately before shift change, “see” the resident and share that location with the oncoming staff member during report. That staff member is to then “see” the new resident before tending to any others they are assigned to and continue with the 20-minute reporting. This shall continue and be charted for two weeks, unless otherwise directed and documented by the Health Oversight (HO) nurse or an Administrator. Both staff members involved have been counseled and that documentation is located in the personnel record.
22VAC40-73-1100-C
Based on record review, the facility failed to document that the order of priority specified in subsection A of this section was followed, and the documentation shall be retained in the resident's file. The order of priority in subsection A is 1. The resident, if capable of making an informed decision; 2. A guardian or other legal representative for the resident if one has been appointed; 3. A relative who is willing… or 4. If the resident is not capable of making an informed decision… an independent physician.
Evidence
  1. The legal guardian approved placement prior to placing Resident #1 in the Special Care Unit; however, Resident #1’s “Approval for Placement in Special Care Unit” document dated 8-19-2022 was blank for the question, “Explanation of why written approval was not obtained from each individual higher on the list of priority.”
Plan of correction
The facility Administrator has amended the Approval For Placement document (that was signed by family prior to placement) with the reason why the first individual of the priority order was not used – the resident, “Self”, was unable to give approval due to her cognitive inability to do so. The second person in the priority order is who gave approval.
22VAC40-73-320-A
Based on record review, the facility failed to ensure the physical examination for the resident by an independent physician contained a description of the person’s reactions to any known allergies.
Evidence
  1. Resident #1 admitted 8-17-2022. Resident #1’s “Report of Resident Physical Examination” dated 7-18-2022 documents the resident is allergic to “PCN [penicillin] and Quinapril”. The report does not include a description of the person’s reactions to either of these medications.
Plan of correction
The expected allergic reactions were immediately added to the resident’s chart by the HO nurse following the exit interview with LI by phone. HO nurse will follow up with MD for confirmation.
22VAC40-73-1110-A
Based on record review, the facility failed to ensure prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee determined whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident's file.
Evidence
  1. Approval for placement documentation was requested of Staff #1 onsite on 9-14-2022. Documentation provided by Staff from Resident #1’s record did not contain a written determination and justification by the licensee, administrator, or designee for Resident #1 to be placed in the safe, secure environment.
Plan of correction
The facility Administrator has completed and signed the correct document and placed in the resident’s chart.
July 8, 2022Complaint survey1 violation
Inspection dates
07/08/2022, 08/09/2022
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¿ 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS¿ ARTICLE 1 – SUBJECTIVITY¿ 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS¿ 63.2 GENERAL PROVISIONS¿ 63.2 PROTECTION OF ADULTS AND REPORTING¿ 63.2 LICENSURE AND REGISTRATION PROCEDURES¿ 63.2 FACILITIES AND PROGRAMS¿ 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES¿ 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION¿ 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT¿ 22VAC40-80 THE LICENSE¿ 22VAC40-80 THE LICENSING PROCESS¿ 22VAC40-80 COMPLAINT INVESTIGATION¿ 22VAC40-80 SANCTIONS
Technical assistance
Consultation is recommendation of separating a delegation statement from other forms (i.e. from ISP).
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: 7/08/2022, 10:10 a.m. – 11:45 a.m. 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 5/11/2022 regarding allegations in the areas of Administration and Administrative Services and Resident Care and Related Services An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Administration and Administrative Services A violation notice was 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-73-80
Based on record review and interview with staff, the facility failed to ensure there was documentation of the resident requesting facility assistance with the management of personal funds via a delegation request signed and dated by the resident.
Evidence
  1. Resident #1 admitted 1-01-2017. Resident #1’s file did not contain a delegation statement.
  2. Staff #1 stated of the delegation statements, “That is a part of their care plan [ISP]” and confirmed they do assist with Resident #1’s management of personal funds; however, there was no delegation statement on Resident #1’s ISP dated 3-29-2022 or anywhere in the record.
Plan of correction
Not published by VDSS.
July 8, 2022Inspection0 violations
Inspection dates
07/08/2022
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¿22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS¿ARTICLE 1 – SUBJECTIVITY¿32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS¿63.2 GENERAL PROVISIONS¿63.2 PROTECTION OF ADULTS AND REPORTING¿63.2 LICENSURE AND REGISTRATION PROCEDURES¿63.2 FACILITIES AND PROGRAMS¿22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES¿22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION¿22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT¿22VAC40-80 THE LICENSE¿22VAC40-80 THE LICENSING PROCESS¿22VAC40-80 COMPLAINT INVESTIGATION¿22VAC40-80 SANCTIONS
Comments
Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: July 8, 2022, 11:46 a.m. – 12:14 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. This was a modification inspection for increasing the capacity on the license from 65 to 75 residents. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 8, 2022Inspection0 violations
Inspection dates
07/08/2022
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¿22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS¿ARTICLE 1 – SUBJECTIVITY¿32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS¿63.2 GENERAL PROVISIONS¿63.2 PROTECTION OF ADULTS AND REPORTING¿63.2 LICENSURE AND REGISTRATION PROCEDURES¿63.2 FACILITIES AND PROGRAMS¿22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES¿22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION¿22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT¿22VAC40-80 THE LICENSE¿22VAC40-80 THE LICENSING PROCESS¿22VAC40-80 COMPLAINT INVESTIGATION¿22VAC40-80 SANCTIONS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: July 8, 2022 12:15 – 12:30 p.m. 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 no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 8, 2022Inspection6 violations
Inspection dates
02/08/2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity22VAC40-90 The Sworn Statement or Affirmation
Comments
An unannounced renewal inspection was initiated on February 3, 2022 by phone and conducted at the facility on February 8, 2022 by licensing staff from 7:21 a.m. to 8:42 a.m. The Exit call was conducted on February 15, 2022 to conclude the inspection. A tour of the facility was conducted which included the following observations: building and grounds, facility postings, meal observations, and staff interviews. Record reviews of resident records, staff records, healthcare oversight, dietary oversight, pharmacy oversight, staff schedules, fire and health inspections, fire and emergency drills was completed. Non-compliance was found in the areas of Personnel, Resident Care and Related Services, and Emergency Preparedness. Thank you for your cooperation during this inspection. I can be reached at Alex.Poulter@dss.virginia.gov or (804) 662-9771.
Violations
22VAC40-73-1090-A
Based on record review and interview with staff, the facility failed to ensure prior to his admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Evidence
  1. Resident #3 admitted to the safe, secure environment on 1-08-2020. Resident #3’s “Assessment of Serious Cognitive Impairment” dated 1-06-2020 by Physician #1 checked “No” to the question, “Does the individual named above have a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his/her own safety and welfare?”
  2. Staff #2 and Staff #3 confirmed during interview that Physician #1 did not assess Resident #3 as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his/her own safety and welfare.
Plan of correction
When the Administrator realized that Resident #3’s PCP had made an error completing the form (checking the wrong box) shortly after admission, she contacted the practice and was informed that the MD had just retired. The new MD that took over the practice stated that he would not make the change since he did not know and had never treated the resident. Since the Administrator is not a physician, we knew we had no authority to change it and with it being an admission form, we didn’t know that it was acceptable to complete a new one after the fact. To correct the violation, we asked our facility physician, who now sees this resident, to complete the form -checking the correct box- and have placed in the resident’s chart even though it is post-admission. The Administrator and other admissions staff will be more diligent going forward in checking admission documentation for any errors.
22VAC40-73-1110-A
Based on record review and interview with staff, the facility failed to ensure prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment (SSE), the licensee, administrator, or designee shall determine whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident's file.
Evidence
  1. The following residents who were admitted to the SSE on the following dates did not have determination and justification by the licensee, administrator, or designee as to whether placement in the special care unit was appropriate: a. Resident #3 admitted 1-08-2020; and b. Resident #4 admitted 12-03-2021.
  2. Staff #2 acknowledged during interview that the aforementioned residents’ did not have written documentation of the determination and justification for placement in the SSE.
Plan of correction
The facility Administrator has edited the department’s Review of Appropriateness of Placement form, creating an ‘Admission Review of Appropriateness’ document to be completed on all residents with a serious cognitive impairment applying for admission to the SSE. This new form showing the Administrator’s determination of appropriate placement was completed for Resident #s 3 and 4 and placed in their file.
22VAC40-73-290-A
Based on record review and interview with staff, the facility failed to maintain a written work schedule that includes the names and job classifications of all staff working each shift.
Evidence
  1. The “Activity Director Schedule” (last updated 11-30-2021) did not document the names of the Activity Director or Activity Assistant for any of the dates.
  2. Staff #3 confirmed that the “Activity Director Schedule” is the written work schedule for the Activities department and stated that “it remains the same week to week (unless otherwise noted)”.
  3. Staff #3 identified Staff #4 as the Activity Director and Staff #5 as the Activity Assistant.
Plan of correction
The activity staff names were added to the schedule and forwarded to the LI.
22VAC40-73-100-A
Based on observation, record review, and interview with staff, the facility failed to ensure the assisted living facility implemented their infection control program addressing the surveillance, prevention, and control of disease and infection that is consistent with the federal Centers for Disease Control and Prevention (CDC) guidelines.
Evidence
  1. Staff #1’s mask was pulled down below Staff #1’s nose and mouth on 2-08-2022 during inspection while administering medications to residents.
  2. Additionally, Staff #1 stated, “The resident [Resident #1] I was speaking to is hard of hearing” when asked why the staff’s mask was pulled down.
  3. The facility’s policy titled “Pandemic Plan (Including Covid-19 update)” revised 6-04-2020 documented under “Policy”… “It is the policy of Hickory Hill RC to effectively respond to any Pandemic Illness and meet the guidelines established by the Centers for Disease Control.” And under “Procedures”… “2. Standard precautions will be maintained in all treatment settings. All staff will wear masks at all times while in the facility.”
  4. The CDC website updated 2-02-2022 under “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic” documented, “Implement Source Control Measures …Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person’s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing.”
  5. Staff #2 acknowledged during interview that Staff #1 was not following the facility’s policy “Pandemic Plan (Including Covid-19 update)”.
Plan of correction
Staff #1 was re-trained on facility’s IC plan. The resident she was speaking to had just moved in a few days prior and is deaf as well as mute. All staff are now using a dry erase board to better communicate with her without compromising IC protocol.
22VAC40-73-550-F
Based on observation and interview with staff, the facility failed to ensure the rights and responsibilities of residents shall be printed in at least 14-point type and posted conspicuously in a public place in all assisted living facilities. The facility shall also post the name and telephone number of the appropriate regional licensing supervisor of the department.
Evidence
  1. The “Rights and Responsibilities of Residents of Assisted Living Facilities” posted onsite was the 2007 version that contained only 19 rights versus the 2013 version that contains 20 rights as per § 63.2-1808 of the Code of Virginia. Additionally, the appropriate regional licensing supervisor of the department was not posted at the time of inspection. Photographic evidence was taken during inspection.
  2. Staff #2 acknowledged during interview that the information was not up to date with the current version of “Rights and Responsibilities of Residents of Assisted Living Facilities” (2013) per § 63.2-1808 of the Code of Virginia and the incorrect regional licensing supervisor’s name was posted.
Plan of correction
The latest version of the Resident Rights & Responsibilities document was obtained from the department’s website, including the correct Regional Licensing Supervisor’s name, and was posted immediately. Photo was then submitted to LI. Assistant Administrator will check the website no less than annually to ensure that all forms and postings are the most recent updates.
22VAC40-90-30-C
Based on record review, the facility failed to ensure that any person did not make a false statement on the sworn statement or affirmation.
Evidence
  1. Staff #6’s date of hire was 4-21-2021. Staff #6’s sworn statement dated 4-27-2021 documented “No” for the question, “Have you ever been convicted of a law violation(s) but excluding offenses committed before your eighteenth birthday that were finally adjudicated in a juvenile court or under a youth offender law?”; however, Staff #6’s “Virginia Criminal Record” dated 5-05-2021 had a conviction.
  2. Staff #2 and Staff #3 acknowledged during interview the form was filled out with a false statement by Staff #6.
Plan of correction
Staff #6 was contacted immediately concerning this error. She stated that she really did not understand the question. (The verbiage really is quite difficult to understand for many.) She corrected her answer on the spot and apologized for the error. Note: She did disclose the conviction on her application. HR has been advised to thoroughly explain this particular question on the disclosure statement to all new applicants when they are completing the form going forward.
September 28, 2021Complaint survey0 violations
Inspection dates
09/28/2021
Areas reviewed
None
Comments
A non-mandated complaint inspection was initiated on September 17, 2021 and concluded on September 28, 2021. A complaint was received by the department regarding allegations in the areas of food and resident care. The Licensee was contacted by telephone to conduct the investigation. The licensing inspector emailed the Licensee a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on September 28, 2021. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 3, 2020Inspection9 violations
Inspection dates
Dec. 3, 2020
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Technical assistance
Technical assistance offered to facility administrator to clarify issues which led to violations of regulations during this inspection. The Licensing Inspector reviewed the following standards with provider: 22VAC-40-73-40.B; 70; 150.C; 325.B; 325.C; 45.F; 460.D; 490.D; 550.H
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 12/03/2020 and concluded on 02/25/2021. The licensing inspector emailed the administrator and assistant administrator a list of documentation required to complete the inspection. The evidence gathered during the inspection supported the determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. The facility Administrator reported that the current census was 44. The inspector reviewed four resident records, four staff records, and other facility documentation such as staff schedules, nurse’s notes, annual review of resident’s rights, physical therapy documentation, staff training, pharmacy review, medication administration records etc. submitted by the facility to ensure documentation was complete. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and returned it to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions please feel free to contact me at (804)662-9774 or by e-mail at Angela.r.reaves@dss.virginia.gov if you have any questions.
Violations
22VAC40-73-40-B-12
Based on the review of facility records the facility failed to ensure that at all times the department's representative is afforded reasonable opportunity to inspect all of the facility's buildings, books, and records and to interview agents, employees, residents, and any person under its custody, control, direction, or supervision as specified in ? 63.2-1706 of the Code of Virginia.
Evidence
  1. Resident #2-Documented date of admission-12/20/2020 Resident #4-Documented date of discharge-05/29/2020 In a 01/14/2021 email to the facility Administrator and the facility’s Assistant Administrator (staff #3) the inspector in part noted the following: For the residents listed (under part 3 of the department’s R&M2 document please send all of the requested documentation. If any of the residents listed are no longer residing at the facility please include the discharge documentation as well as the nurse’s notes for the last three months the resident was in care at the facility?. The inspector’s 01/14/2021 email identified resident #s 2 and 4 as well as specific facility records that was to be submitted. 02/17/2021: The inspector submitted a follow up email to the facility’s Assistant Administrator and the facility Administrator clarifying the 01/14/2021 email request for specific documentation. The facility rent roll document that was submitted for the inspector’s review notes that resident #2 resides in the facility? s safe and secure unit of the facility. As of 02/23/2021 and upon request the facility did not submit for the inspector’s review documented evidence that review of the appropriateness of the resident's continued residence in the safe and secure care unit was performed. As of 02/23/2021 and upon request the facility did not submit for the inspector’s review documentation of the Uniform Assessment Instrument (UAI), Individualized Service Plan (ISP) documentation, admission physical examination forms if resident #4 was admitted within the past year, most recent TB screening, all current physician’s orders (i.e. medications, treatments, home health, etc.), Medication/Pharmacy review and recommendation follow-up, most recent acknowledgement of Resident Rights & Responsibilities review, most recent Fall risk rating, nurses? notes/charting notes for the past 3 months as well as Special Care Unit admission and continued placement forms if applicable to resident #4.
Plan of correction
Not published by VDSS.
22VAC40-73-70-A
Based on the review of facility records and email correspondence, the facility failed to submit within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. Resident #1-Documented date of admission 12/9/2016. Documented date of discharge 10/19/2020. Responding to an inquiry from the inspector for documentation of the resident’s most recent physical examination report, the facility submitted via a 10/07/2020 email that in part notes ?The most recent physical exam was done just this past Thursday, Oct. 1, and has not been received to the resident's chart yet from (doctor identified). Their office is forwarding to us now and we will then send to you upon receipt.? Later on 10/07/2020 the department received an email from the facility that in part notes ?physical examination documentation (resident #1 identified) from (doctor is identified) is attached.? The document referenced in the 10/07/2021 email in part notes on page 4/5 under the heading ENCOUNTER 10/01/2020: ?Pt is s/p fall on 9/17 while attempting to go from bathroom to her room. She was sent to ER post fall and did not suffer any fractures, but continued to c/o pain.? Facility documentation submitted revealed that the resident had a medical incident on 09/17/2020 that required outside emergency medical intervention but did not submit an incident report to the department as required.
Plan of correction
Not published by VDSS.
22VAC40-73-150-C
Based on the review of facility records and interviews conducted the Administrator failed to be responsible for the general administration and management of the facility, did not oversee the day-to-day operation of the facility, did not ensure that care is provided to residents in a manner that protects their health, safety, and well-being and did not ensure the development, implementation, and monitoring of an Individualized Service Plan (ISP) for each resident.
Evidence
  1. Resident #1-Documented date of admission 12/9/2016. Documented date of discharge 10/19/2020. (1)-The Department received a report from the local Adult Protective Services agency on 10/08/2020 that in part noted ? The client was brought to the hospital on October 2, 2020 with bilateral femur fractures. The facility stated the client was found on the floor by the staff. The client stated, the aide was taking her out of bed to put in her into a chair. The client told the aide she requires two people to assist her in this task. The aide responded “it ok I got this” The client stated as aide pivoted her to get into the chair the aide dropped her, causing the client’s legs to break?. ? Documentation the department received from a local hospital regarding the fall resident #1 sustained at the facility on 10/02/2020 notes on page 1/88 under the heading MEDICAL DIAGNOSES: THIS VISIT=?Right femoral shaft fracture, Left femur fracture, Left tibal plateau fracture and Left clavicle fracture.? “ The documentation from the local hospital also notes on page 6/88 ”(Resident #1 identified by name) was admitted to orthopedic surgery status post fall while transferring sustaining the multiple injuries as detailed below-She was then taken to the OR on 10/3 as detailed in operative note. Orthopedic injuries: left comminuted supracondylar femur fracture; left lateral split depressed tibial plateau fracture; right long oblique femoral shaft fracture and left medical clavicle fracture (non-op).? ? The resident’s most recent ISP dated 09/18/2020 that the facility submitted for the inspector’s review noted that the resident was to have two person assist with transfers. ? The Visit Notes Report document dated 09/22/2020 (11 days before the 10/02 fall) from the resident’s physical therapist that the facility submitted for the inspector’s review notes on page 12/22: ?MOBILITY ROLL LEFT AND RIGHT; THE ABILITY TO ROLL FROM LYING ON BACK TO LEFT AND RIGHT SIDE AND RETURN TO LYING ON BACK ON THE BED; The therapist noted: SUBSTANTIAL/MAXIMAL ASSISTANCE-HELPER DOES MORE THAN HALF THE EFFORT. HELPER LIFTS OR HOLD TRUNK OR LIMBS AND PROVIDES MORE THAN HALF THE EFFORT?-indicating that the resident lacked the ability roll from side to side or to get off of her bed without the assistance of another person. “ The facility Administrator’s 10/04/2020 self-reported resident incident regarding the 10/02/2020 fall in part notes ”She was found on the floor by facility (staff #2 identified) while doing rounds.? The facility Administrator’s self-reported resident incident only identified staff #2 but did not identify an additional facility direct care staff person that was present in the resident’s room or assigned to assist facility staff #2 with the two person assist with transfers. “ The facility’s DOCUMENTATION FORM dated ”Oct, 2, 2020? written and signed by facility staff #2 that was submitted by the facility for the inspector’s review notes: ?I found (resident #1 identified) on the floor, I was going to her room to get her for lunch. She told me her knees got weak and she fell.? **Due to the volume of information gathered during the inspection, a separate document has been created and is available upon request.***
Plan of correction
Not published by VDSS.
22VAC40-73-325-B
Based on the review of facility records the facility failed to ensure that a fall risk rating was reviewed and updated after each fall.
Evidence
  1. Resident #1-Documented date of admission 12/9/2016. Documented date of discharge 10/19/2020. The facility’s most recent physical examination report from (doctor identified) dated 10/07/2020 that the facility submitted for the inspector’s review noted that the resident had a fall on 09/17/2020. Upon request the facility did not submit for the inspector’s review documented evidence that a fall risk assessment was conducted regarding this fall.
Plan of correction
Not published by VDSS.
22VAC40-73-325-C
Based on the review of facility records the facility failed to ensure that documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls is maintained
Evidence
  1. Resident #1-Documented date of admission 12/9/2016. Documented date of discharge 10/19/2020. The facility’s most recent physical examination report from (doctor identified) dated 10/07/2020 that the facility submitted for the inspector’s review noted that the resident had a fall on 09/17/2020. Upon request the facility did not submit for the inspector’s review documented evidence that an analysis of the residents? fall that occurred on 09/17/2020 was conducted.
Plan of correction
Not published by VDSS.
22VAC40-73-450-F
Based on the review of facility records the facility failed to ensure that Individualized Service Plans (ISP) were reviewed and updated at least once every 12 months and as needed as the condition of the resident changes. The review and update shall be performed in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons.
Evidence
  1. Resident #1- Documented date of admission 12/9/2016. Documented date of discharge 10/19/2020. Upon request to review the resident’s most recent Individualized Service Plan (ISP) the facility submitted a two page ISP document dated 12/17/2019 and a handwritten entry by staff #1 indicating an update of the ISP on 09/18/2020. (1)- The Visit Note Report document from the identified home health agency dated 02/11/2020 that was submitted for the inspector’s review on 02/23/2021 notes in part on page 2/21 under the heading Diagnosis/Procedures: HISTORY OF FALLING (2)- The Visit Note Report document from the identified home health agency dated 02/11/2020 notes on page 3/21 under the heading Assessment: ? DATE OF REFERRAL: INDICATE THE DATE THAT THE WRITTEN OR VERBAL REFERRAL FOR INITIATION OR RESUMPTION OF CARE WAS RECEIVED BY THE HHA. The date noted is “02/22/2020”. (3)- The Visit Note Report document from the identified home health agency dated 02/11/2020 notes on page 10/21 under the heading Assessment: ? HAS THE PATIENT HAD A MULTI-FACTOR FALLS RISK ASSESSMENT: USING A STANDARDIZED VALIDATED ASSESSMENT TOOL?“ The therapist noted ”2-YES, AND IT DOES INDICATE A RISK FOR FALLS.? The facility did not update the resident’s 12/17/2019 Individualized Service Plan based on the 02/11/2020 Visit Note Report from the physical therapist documenting that service to the resident was initiated/resumed on 02/11/2020. Additionally the Visit Note Report document from the identified home health agency dated 09/22/2020; five days after the resident’s 09/17/2020 fall that the facility submitted for the inspector’s review on 02/23/2021 notes on page 4/22 under the heading Assessment: ?RISK FOR HOSPITALIZATION: WHICH OF THE FOLOIWNG: SIGNS OR SYMPTOMS CHARACTERIZE THIS PATIENT AS AT RISK FOR HOSPITALIZATION? (MARK ALL THAT APPLY) 1-HISTORY OF FALLS (2 OR MORE FALLS-OR ANY FALL WITH AN INJURY-IN THE PAST 12 MONTHS?. ?On page 9/22 of the identified home health agency’s Visit Note Report document under the heading Assessment notes ?ACCORDING TO THE MAHC FALL RISK ASSESSMENT THIS PATIENT S SCORE IS 7. BASED ON THE SCORE THE PATIENS IS AT RISK FOR FALLING. The resident’s 09/18/2020 ISP was not updated to reflect the physical therapist assessment that the resident was at risk for falls and hospitalization. A handwritten entry dated 09/30/2020 on the resident’s ISP notes “OT started (PT eval)”.
Plan of correction
Not published by VDSS.
22VAC40-73-460-D
Based on the review of facility records and interviews conducted the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs.
Evidence
  1. Resident #1- Documented date of admission 12/9/2016. Documented date of discharge 10/19/2020. As part of the department’s remote renewal inspection the licensing inspector requested specific documentation from the facility regarding the assessed needs and services provided to the resident based on assessed needs while in care at the facility. The documentation submitted from the facility noted the following: (1)-The resident had documented falls while in care at the facility on 09/17/2020 and less than a month later on 10/02/2020. (2)-The resident’s Uniform Assessment Instrument dated 09/18/2020 signed by the facility Administrator noted ? Mechanical and Human Help with transferring with a check in the physical assistance column, walking is noted as Mechanical and Human Help with a check in the supervision column. (3)-The resident’s most recent 09/18/2020 Individualized Service Plan (ISP) that the facility submitted for the inspector’s review revealed a handwritten entries that notes: “ Under the heading Mobility: ”9/18/2020- Needs additional assistance due to weakness related to fall on 9-17-2020.? Under the heading Planned Activities the handwritten entry on the ISP notes in part ?2 person assist with transfer notify SV of any changes in mobility.? (4)- The Visit Note Report document from the identified home health agency dated 09/22/2020; five days after the resident’s 09/17/2020 fall that the facility submitted for the inspector’s review on 02/23/2021 notes the following: “Page 9/22 under the heading ”FUNCTIONAL TESTS AND MEASURES- PLEASE COMPLETE THE FOLLOWING QUESTIONS AS RELATED TO THE ELDERLY MOBIILTY SCALE: ?LYING TO SITTING-NEEDS HELP OF 1 PERSON. ?Page 10/22: SITTING TO LYING-NEEDS HELP OF 1 PERSON; SIT TO STAND-NEEDS HELP OF 2 + PEOPLE; STANDING- STAND ONLY WITH PHYSICAL SUPPORT OF 1 PERSON; GAIT-REQUIRES PHYSICAL ASSISTANCE OR CONSTANT SUPERVISION. The document from the home health agency also notes on page 10/22 under the heading - BASED ON THE TOTAL SCORE THE CLIENT S ELDERLY MOBILITY LEVEL IS: ?EMS-DEPENDENT. (5)- The Visit Note Report document from the identified home health agency dated 09/23/2020 that the facility submitted for the inspector’s review notes on page 5/7 under the heading Therapy Goal/Status: ?FUNCTIONAL; BED MOBILITY; SUPINE TO SIT-STATUS: UNABLE /TOTAL DEPENDENCE. GOAL MET:N? (6)- The Visit Note Report document from the identified home health agency dated 09/28/2020 notes on page 4/7 under the heading Therapy Goal/Status: “FUNCTIONAL; BED MOBILITY; ROLL TO SIDE-STATUS: MAXIUM ASSIST”. (7)-The resident’s most recent health and physical examination document with an ENCOUNTER date of 10/01/2020; 1 day before the resident’s 10/02/2020 fall in part notes on page 4/5 and 5/5 under the heading DIAGNOSIS: Chronic pain; Osteoarthritis; contusions of hip, rib; Primary OA of right knee, arthritis of both knees; Edema of the leg; Bursitis of left hip, Pain in left hip.? **Due to the volume of information gathered during the inspection, a separate document has been created and is available upon request.***
Plan of correction
Not published by VDSS.
22VAC40-73-490-D
Based on the review of facility records the facility failed to ensure that the health care oversights were conducted on facility residents.
Evidence
  1. Upon request to review the most recent healthcare oversight performed on facility residents, the facility submitted a healthcare document noting a beginning date of 01/14/2021 with an ending date of 01/08/2021. The document does note recommendations for change/comments as needed but the document does not identify specific residents for whom the oversight was provided and was not signed indicating that a health care professional had conducted the oversight.
Plan of correction
Not published by VDSS.
22VAC40-73-550-H
Based on the review of facility records the facility failed to ensure that a resident’s legal representative signed the annual review of resident’s rights. If a resident is unable to fully understand and exercise the rights and responsibilities contained in ? 63.2-1808 of the Code of Virginia and does not have a legal representative, the facility shall require that a responsible individual, of the resident's choice when possible, designated in writing in the resident's record annually be made aware of each item in “ 63.2-1808 and the decisions that affect the resident or relate to specific items in ” 63.2- 1808. The responsible individual shall not be the facility licensee, administrator, or staff person or family members of the licensee, administrator, or staff person.
Evidence
  1. Resident #2-Documented date of admission 12/20/2018 Resident #3-Documented date of admission 04/19/2019 The facility’s rent roll document that was submitted for the inspector’s review via an email on 12/08/2020 notes that resident #s 2 and 3 resides on the facility’s memory care unit. The facility’s Rights and Responsibilities of Residents in Assisted Living Facilities document that the facility submitted for the inspector review on 01/15/2021 noted that the facility Administrator signed the document on 02/26/2020 for both residents. For both residents the individual facility’s Rights and Responsibilities of Residents in Assisted Living Facilities document notes ?The following resident is unable to fully understand the rights and responsibilities contained in this section due to a severe cognitive disability. Therefore, the Administrator of Hickory Hill Retirement Community will be the responsible individual, aware of each item in this section, and the decisions that affect the resident or relate to specific items in this section.? Upon request the facility submitted for the inspector’s review via a 02/23/2021 email documentation of the assigned Power of Attorney document for resident #2. Upon request in a 01/14/2021 email to the facility Administrator and assistant facility administrator the facility did not submit for the inspector’s review documented evidence that annual review of resident rights had been conducted with resident #s 2 and 3 or with an individual acting on behalf of the resident’s as allowed by current Regulations for Licensed Assisted Living Facilities.
Plan of correction
Not published by VDSS.
July 1, 2020Complaint survey0 violations
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
Comments
A non-mandated complaint inspection was initiated on July 1, 2020 and concluded on March 25, 2021. A complaint was received by the department regarding allegations of infection control practices. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.