VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hickory Hill Retirement Community
900 Cary Shop Road
Burkeville, VA 23922
(434) 767-4225

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: Dec. 3, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

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:

Standard #:	22VAC40-73-40-B-12
Description:	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: 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 available online. Contact Inspector for more information.
Standard #:	22VAC40-73-70-A
Description:	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: 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 available online. Contact Inspector for more information.
Standard #:	22VAC40-73-150-C
Description:	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: 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 available online. Contact Inspector for more information.
Standard #:	22VAC40-73-325-B
Description:	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: 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 available online. Contact Inspector for more information.
Standard #:	22VAC40-73-325-C
Description:	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: 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 available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	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: 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 available online. Contact Inspector for more information.
Standard #:	22VAC40-73-460-D
Description:	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: 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 available online. Contact Inspector for more information.
Standard #:	22VAC40-73-490-D
Description:	Based on the review of facility records the facility failed to ensure that the health care oversights were conducted on facility residents. Evidence: 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 available online. Contact Inspector for more information.
Standard #:	22VAC40-73-550-H
Description:	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: 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 available online. Contact Inspector for more information.