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: March 14, 2023

Complaint Related: No

Areas Reviewed:

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

Standard #:	22VAC40-73-40-A
Description:	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. 4. 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 available online. Contact Inspector for more information.
Standard #:	22VAC40-73-110-1
Description:	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 available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-A
Description:	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: 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.