Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 23, 2025
Visit Reason
The inspection was conducted in response to a complaint received on January 13, 2025, regarding allegations related to maintenance of buildings and grounds at Hickory Hill Retirement Community.
Findings
The licensing inspector conducted a tour of the physical plant and inspected the resident's room in question. The resident was relocated while extermination and sanitation procedures were implemented. The investigation did not find evidence to support the allegation of non-compliance with standards or law.
Complaint Details
Complaint was related to maintenance of buildings and grounds. The evidence gathered did not support the allegation of non-compliance.
Report Facts
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Coy Stevenson | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 3, 2024
Visit Reason
The inspection was conducted in response to a complaint received on November 25, 2024, regarding allegations of resident care issues and unsanitary conditions at the facility.
Findings
During the on-site inspection on December 3, 2024, the licensing inspector reviewed resident monitoring procedures for skin break-down prevention and infection control measures. Observations of communal areas, resident rooms, and interactions found no health or safety concerns.
Complaint Details
Complaint received regarding resident care and unsanitary conditions; no health or safety concerns were noted during inspection.
Inspection Report
Renewal
Census: 73
Deficiencies: 1
Dec 3, 2024
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with applicable standards related to employee orientation training requirements, resulting in documented violations.
Deficiencies (1)
| Description |
|---|
| 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. |
Report Facts
Number of residents present: 73
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 19, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-10-07 alleging staff substance abuse, verbal and physical abuse of residents, and resident neglect at Hickory Hill Retirement Community.
Findings
The investigation included an interview with the facility administrator who denied all allegations. No evidence was found to support the complaint allegations, and the inspection concluded with no substantiated non-compliance.
Complaint Details
Complaint related to staff substance abuse while at the facility; verbal and physical abuse of residents; resident neglect. The evidence gathered did not support the allegations of non-compliance.
Report Facts
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 17, 2024
Visit Reason
The inspection was conducted in response to a complaint received on April 10, 2024, alleging that residents' freedom of movement was being restricted at the facility.
Findings
The inspection found that residents were observed moving about the facility freely and the facility was in good repair with safe grounds. The administrator denied that the individuals named in the complaint were current residents or employees.
Complaint Details
The complaint alleged that residents' freedom of movement was being restricted. The administrator stated that the individuals named as residents or employees in the complaint were not associated with the facility. Observations during the inspection did not support the complaint.
Report Facts
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
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 0
Oct 18, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-08-22 regarding allegations in the areas of Resident Care and Buildings and Grounds.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection findings will be posted publicly.
Complaint Details
Complaint received on 2023-08-22 regarding Resident Care and Buildings and Grounds; investigation did not substantiate the allegations.
Inspection Report
Renewal
Census: 62
Deficiencies: 0
Oct 18, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility.
Findings
The inspection found no violations with applicable standards or laws. An exit meeting was conducted to review the findings, and the inspection summary will be posted publicly.
Inspection Report
Monitoring
Census: 64
Deficiencies: 3
Mar 14, 2023
Visit Reason
The inspection was a monitoring visit conducted on March 14, 2023, following a self-reported incident received on February 27, 2023, regarding allegations in the areas of personnel and resident care.
Findings
The investigation supported the self-report of non-compliance with violations issued related to sexual abuse by a staff member against a resident, failure to ensure staff were considerate and respectful of residents' rights and dignity, and incomplete documentation of allergic reactions in the resident's physical examination record.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure compliance with its own policies and procedures related to sexual abuse between a staff member and a resident. |
| Facility failed to ensure staff were considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled. |
| Facility failed to ensure that the physical examination preceding admission contained a description of the person’s reactions to known allergies. |
Report Facts
Number of residents present: 64
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 3
Inspection Report
Renewal
Census: 68
Deficiencies: 2
Jan 12, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the Hickory Hill Retirement Community to assess compliance with applicable standards and laws.
Findings
The inspection found non-compliance with applicable standards, including failure to report major incidents to the regional licensing office within 24 hours and failure to update individualized service plans for significant changes in residents' conditions.
Deficiencies (2)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident. |
| Facility failed to ensure individualized service plans (ISPs) were reviewed and updated as needed for a significant change of a resident's condition. |
Report Facts
Number of residents present: 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
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Retrained Staff #2 on reporting requirements and discussed violation related to individualized service plans | |
| Staff #2 | Failed to report incidents and update individualized service plans; was retrained and discussed violations |
Inspection Report
Monitoring
Deficiencies: 4
Sep 14, 2022
Visit Reason
The inspection was a monitoring visit conducted on September 14, 2022, following a self-reported incident regarding resident care and related services.
Findings
The investigation supported the self-report of non-compliance with several standards related to resident care, documentation, and supervision. Violations were issued concerning failure to document approval for placement, failure to justify placement in a special care unit, incomplete physical examination documentation, and inadequate supervision leading to a resident elopement.
Deficiencies (4)
| Description |
|---|
| Failed to document that the order of priority for placement approval was followed and retained in the resident's file. |
| Failed to ensure a written determination and justification for placement of a resident with serious cognitive impairment in a safe, secure environment. |
| Failed to ensure the physical examination documented the resident's reactions to known allergies. |
| Failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering from the premises. |
Report Facts
Duration of elopement: 2
Inspection time: 1
Plan of correction submission timeframe: 5
Review request timeframe: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Poulter | Licensing Inspector | Contact person for questions regarding the inspection. |
| Coy Stevenson | Current Inspector | Named as current inspector for the facility. |
Inspection Report
Monitoring
Deficiencies: 0
Jul 8, 2022
Visit Reason
The inspection was a monitoring visit conducted to review compliance with various regulatory provisions for the assisted living facility.
Findings
The inspection found no violations with applicable standards or laws. The inspection summary will be posted publicly and a copy of the findings is required to be posted on the facility premises.
Inspection Report
Capacity: 75
Deficiencies: 0
Jul 8, 2022
Visit Reason
This was a modification inspection for increasing the capacity on the license from 65 to 75 residents.
Findings
The inspection reviewed multiple regulatory areas related to assisted living facilities, including administration, personnel, resident care, emergency preparedness, and licensing procedures. No complaint was related to this inspection.
Report Facts
Licensed capacity increase: 10
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 8, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2022-05-11 regarding allegations in the areas of Administration and Administrative Services and Resident Care and Related Services.
Findings
The investigation supported some, but not all, of the allegations; non-compliance was found in Administration and Administrative Services. A violation notice was issued related to failure to document resident delegation for assistance with management of personal funds.
Complaint Details
Complaint was substantiated in part; non-compliance found in Administration and Administrative Services related to delegation documentation.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure documentation of the resident requesting facility assistance with management of personal funds via a delegation request signed and dated by the resident. |
Inspection Report
Renewal
Deficiencies: 6
Feb 8, 2022
Visit Reason
An unannounced renewal inspection was initiated by phone on February 3, 2022 and conducted at the facility on February 8, 2022 to assess compliance with licensing requirements.
Findings
Non-compliance was found in the areas of Personnel, Resident Care and Related Services, and Emergency Preparedness. Specific deficiencies included failure to properly assess residents with serious cognitive impairment, inadequate infection control practices, incomplete staff work schedules, outdated resident rights postings, and false statements on sworn statements by staff.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure prior to admission that a resident was assessed by an independent clinical psychologist or physician as having a serious cognitive impairment due to dementia. |
| Facility failed to determine and justify in writing whether placement in the special care unit was appropriate for residents with serious cognitive impairment. |
| Facility failed to implement infection control program consistent with CDC guidelines; staff observed not wearing mask properly. |
| Facility failed to maintain a written work schedule including names and job classifications of all staff working each shift. |
| Facility failed to post updated rights and responsibilities of residents and correct regional licensing supervisor information. |
| Facility failed to ensure that any person did not make a false statement on the sworn statement or affirmation. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 28, 2021
Visit Reason
A non-mandated complaint inspection was initiated due to a complaint received regarding allegations in the areas of food and resident care.
Findings
The evidence gathered during the investigation did not support the allegations or self-report of non-compliance with standards or law.
Complaint Details
A complaint was received by the department regarding allegations in the areas of food and resident care. The investigation concluded with no substantiated non-compliance.
Inspection Report
Renewal
Census: 44
Deficiencies: 9
Dec 3, 2020
Visit Reason
A renewal inspection was initiated on 12/03/2020 and concluded on 02/25/2021 to assess compliance with applicable standards and regulations for Hickory Hill Retirement Community.
Findings
The inspection identified multiple violations including failure to provide reasonable opportunity for inspection of records, failure to submit major incident reports timely, inadequate administration and oversight by the facility administrator, failure to update fall risk assessments and individualized service plans, insufficient supervision of residents, and failure to ensure annual review of resident rights by legal representatives.
Deficiencies (9)
| Description |
|---|
| Facility failed to ensure department's representative had reasonable opportunity to inspect all buildings, books, records, and interview relevant persons. |
| Facility failed to submit within 24 hours any major incident negatively affecting or threatening resident life, health, safety, or welfare. |
| Administrator failed to be responsible for general administration and management, including oversight of care and development of Individualized Service Plans (ISP). |
| Facility failed to ensure fall risk rating was reviewed and updated after each fall. |
| Facility failed to maintain documentation of analysis of fall circumstances and interventions to prevent subsequent falls. |
| Facility failed to ensure Individualized Service Plans were reviewed and updated at least annually and as needed. |
| Facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs. |
| Facility failed to ensure health care oversights were conducted on residents with proper documentation and signatures. |
| Facility failed to ensure resident's legal representative signed the annual review of resident rights as required. |
Report Facts
Resident census: 44
Inspection period: 84
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 1, 2020
Visit Reason
A non-mandated complaint inspection was initiated due to a complaint received regarding allegations of infection control practices at Hickory Hill Retirement Community.
Findings
The investigation concluded that the evidence did not support the allegation of non-compliance with standards or law related to infection control.
Complaint Details
Complaint related to infection control practices; investigation did not substantiate the allegations.
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