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: Jan. 12, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 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:

Standard #:	22VAC40-73-70-A
Description:	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.
Standard #:	22VAC40-73-450-F
Description:	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.