VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Carriage Hill Retirement
1203 Roundtree Drive
Bedford, VA 24523
(540) 586-5982

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Jan. 16, 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 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 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:

The LI for Carriage Hill in conjunction with two other LIs and under the supervision of the LA conducted an unannounced monitoring inspection on 01/16/2020 from 9:10am until 6:30pm. Sixty five residents were in care at the time of the inspection. A tour of the physical plant, staff/resident interviews, and audits of the medication carts were conducted. Eight resident and four staff records were reviewed. The criminal record check and sworn disclosures were reviewed for all new hired staff. Observation of partial activities and medication passes were conducted. Findings were reviewed with facility staff during the inspection. An exit interview was conducted with the Administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to your licensing inspector 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, contact your licensing inspector at (540) 589-5216.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on documentation review, the facility failed to implement their medication management plan regarding methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes and failed to successfully implement the medication management plan for methods to ensure the effective use of the medication administration records (MARs) for documentation. EVIDENCE: 1. The facility?s current medication management plan states that each controlled substance will be tracked using a separate Controlled Medication Log which meets the requirements of state and federal narcotic enforcement agencies. At the end of each shift, the outgoing and incoming RN, LPN or RMA authorized to administer medications, will count all controlled substances and sign the Controlled Medication Log verifying the count is accurate. 2. The SHIFT TO SHIFT MAR REVIEW DOCUMENTATION LOG for the memory care center (upper building) was missing signatures for the following dates/times: 01/01/2020; 11P-7A leaving, 01/12/2020; 7A-3P leaving, 01/13/2010; 7A-3P coming and 7A-3P leaving, 01/14/2020; 11P-7A coming, 01/15/2020; 11P-7A leaving and 11P ? 7A coming, and 01/16/2020; 11P-7A leaving. 3. The SHIFT TO SHIFT MAR REVIEW DOCUMENTATION LOG for one of the medication carts in the lower building was missing signatures for the following dates/times: 01/06/2020; 11P-7A coming, 01/07/2020; 11P-7A leaving and 11P-7A coming, 01/08/2020; 11P-7A leaving, 01/09/2020; 7A-3P coming, 7A-3P leaving, 3P-11P coming and 3P-11P leaving, 01/14/2020; 11P-7A coming, 01/15/2020; 11P-7A leaving and 11P-7A coming, 01/16/2020; 11P-7A leaving, 3P-11P coming, 3P-11P leaving and 11P-7A coming. 4. The SHIFT TO SHIFT MAR REVIEW DOCUMENTATION LOG for one of the medication carts for the lower building was missing signatures for the following dates/times: 01/06/2020; 11P-7A coming, 01/07/2020; 11P-7A leaving and 11P-7A coming, 01/08/2020; 11P-7A leaving, 01/13/2020; 7A-3P leaving, 01/14/2020; 7A-3P leaving and 11P-7A coming, 01/15/2020 11P-7A leaving and 11P-7A coming and 01/16/2020; 11P-7A leaving. 5. The January 2020 MAR for resident 3 showed PRN Narcan 4mg nasal spray was administered at 8:48am on 1/15 for overdose. The effectiveness was documented at 10:17am on 1/15 as ?Resident States no further complaints of pain?. The Narcan on site for this resident had not been opened. Interviews with facility staff revealed the resident had not experienced an overdose. 6. The January 2020 MAR for resident 3 showed PRN Unisom Sleep Aid 25 mg tablet was administered for sleeplessness on 1/1, 1/13, 1/14, and 1/15; however, the effectiveness for each of these administrations was documented as ?Resident States no further complaints of pain?. 7. The January 2020 MAR for resident 3 shows Lorazepam was administered on 1/1, 1/14, and 1/15 for anxiety; however, the effectiveness for each of these administrations was documented as ?Resident States no further complaints of pain?.
Plan of Correction:	1. A new controlled medication log was implemented, and the old form was destroyed and removed from facility master documents on 1/22/2020. Date corrected: 1/22/2020 2. Staff was educated and in-serviced on day of inspection regarding proper procedures and documentation required by RMAs/Nurse on shift to shift controlled medication count logs and again on 1/22/2020 with staff on duty when new forms were implemented and 1/23/2020 with remainder of staff and were educate that a new sheet would be used and proper procedures and documentation requirements regarding the counting and signing off on shift to shift controlled medication count logs. Administrator and/or Designee will do a minimum of weekly audits to ensure compliance is met. Date Corrected: 1/23/2020 3. Staff was educated and in-serviced on day of inspection regarding proper procedures and documentation required by RMAs/Nurse on shift to shift controlled medication count logs and again on 1/22/2020with staff on duty when new forms were implemented and 1/23/2020 with remainder of staff and were educate that a new sheet would be used and proper procedures and documentation requirements regarding the counting and signing off on shift to shift controlled medication count logs. Administrator and/or Designee will do a minimum of weekly audits to ensure compliance is met. Date Corrected: 1/23/2020 4. Staff was educated and in-serviced on day of inspection regarding proper procedures and documentation required by RMAs/Nurse on shift to shift controlled medication count logs and again on 1/22/2020 with staff on duty when new forms were implemented and 1/23/2020 with remainder of staff and were educate that a new sheet would be used and proper procedures and documentation requirements regarding the counting and signing off on shift to shift controlled medication count logs. Administrator and/or Designee will do a minimum of weekly audits to ensure compliance is met. Date Corrected: 1/23/2020 5. RMA #2 was coached on 1/17/2020 on proper use of eMAR system and appropriate documentation of PRN medications and documenting results and 1/23/2020 with remainder of staff. Administrator and/or Designee will perform a minimum of weekly audits to ensure proper results are recorded and compliance is met. Date Corrected: 1/23/2020 6. RMA #2 was coached on 1/17/2020 on proper use of eMAR system and appropriate documentation of PRN medications and documenting results and 1/23/2020 with remainder of staff. Administrator and/or Designee will perform a minimum of weekly audits to ensure proper results are recorded and compliance is met. Date Corrected: 1/23/2020 7. RMA #2 was coached on 1/17/2020 on proper use of eMAR system and appropriate documentation of PRN medications and documenting results and 1/23/2020 with remainder of staff. Administrator and/or Designee will perform a minimum of weekly audits to ensure proper results are recorded and compliance is met. Date Corrected: 1/23/2020
Standard #:	22VAC40-73-680-D
Description:	Based on observation and document review, the facility failed to ensure that a medication aide administered medications in accordance with the prescriber?s order and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. At approximately 9:08AM, two LIs observed staff 2 with three small cups of medications, which she identified as belonging to residents 4, 9, and 10. She proceeded to administer the medications to resident 4, in the dining room, and residents 9 and 10 in their bedroom. The three small cups were pre-poured, which is prohibited in section 1.4, E, 3 in the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. 2. At approximately 9:08AM, two LIs observed staff 2 passing medications without wearing identification as required by the Board of Nursing Regulations Governing Medication Aides, which is covered in Chapter 1, Objective 1.3 of the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Plan of Correction:	1. RMA #2 was coached, counselled and educated on proper medication administration on day of inspection and 1/23/2020 with remainder of staff. Administrator and/or designee will perform a minimum of weekly medication administration audits for 30 days to ensure proper medication administration and compliance is met. Date Corrected: 1/23/2020 2. RMA was provided name tag on 1/16/2020 and instructed that name tag must be worn while on duty. Administrator and/or designee will perform a minimum of weekly audits to ensure all staff is wearing a name tag to ensure compliance is met. Date Corrected: 1/17/2020
Standard #:	22VAC40-73-860-G
Description:	Based on tour of the physical plant, the facility failed to ensure that hot water taps available to residents shall be maintained within a range of 105 degrees Fahrenheit to 120 degrees Fahrenheit (F). EVIDENCE: 1. The hot water tap in the bathroom for resident 1 measured 126F and for resident 2 measured 128F.
Plan of Correction:	1. Maintenance checked water temperatures in these two rooms daily for seven days and each recording followed the range of 105-120 degrees Fahrenheit. Administrator, Maintenance and/or designee will perform a minimum of weekly audits to ensure water temperatures are maintained within appropriate ranges. Date Corrected. 1/28/2020
Standard #:	22VAC40-73-860-I
Description:	Based on tour of the physical plant, the facility failed to ensure that cleaning supplies and other hazardous materials were in a locked area. EVIDENCE: 1. The door to the housekeeping closet located in the memory care unit was not locked. The housekeeping closet contained the following cleaning supplies, which were accessible to the residents: a container of non ? acid bathroom cleaner, a container of general purpose cleaner, a container of glass cleaner, a bottle of enzymatic foul odor organic stain eliminator, a bottle of La Bamba lavender multi-purpose cleaner, a container of aqua-sponge, a gallon container of bleach, a gallon container of delimer, a spray bottle of glass and multi-purpose cleaner, a container of non-acid disinfectant restroom cleaner and a container of Red Max Pro low ? maintenance floor finish. 2. The housekeeping cart was also located in the housekeeping closet and was not locked. The housekeeping cart contained a bottle of spic and span and a container of comet.
Plan of Correction:	1. New keyed entry lock was placed on housekeeping closet door located in SCU on day of the inspection to prevent the door from being able to be manually unlocked . Date to be corrected: 1/16/2020 2. New keyed entry lock was placed on housekeeping closet door located in SCU on day of the inspection to prevent the door from being able to be manually un-locked. Date to be corrected: 1/16/2020
Standard #:	22VAC40-73-870-A
Description:	Based on tour of the physical plant, the facility failed to ensure that the interior of all buildings were maintained in good repair and kept clean and free of rubbish. EVIDENCE: 1. At approximately 9:15AM a pile of crumbs was observed in the first hallway to the left in the assisted living building. The crumbs were still there at 10:05AM.
Plan of Correction:	1. Implemented new housekeeping checklist to ensure that the interior of the building is maintained and kept clean and free of rubbish. Administrator and/or designee will perform a minimum of weekly audits to ensure compliance is met Date Corrected: 1/31/2020
Standard #:	22VAC40-73-930-D
Description:	Based on a review of resident records and facility documentation, the facility failed to ensure that each resident with an inability to use the signaling device met the following required components of this standard. EVIDENCE: 1. The records for residents 1 and 2 included a CALL BELL RATING form, showing that each resident was unable to use the call bell to signal for assistance and rounds would be completed on the resident every 2 hours. However, the current individualized service plans (ISPs) for residents 1 and 2, showed ?staff will periodically check on Resident throughout shifts(s) while awake. Staff will check on and document a minimum of every 2 hours while asleep.? 2. The facility documents rounds on a MEMORY CARE ROUND LOG, which showed rounds are scheduled for 8P, 10P, 12AM, 2AM, 4AM, and 6AM. The log does not include documentation of daytime rounds. The January 2020 MEMORY CARE ROUND LOG for resident 2 was missing documentation to show the following rounds were completed as scheduled: 8P and 10P on January 4, 5, 7, 13, and 15; and 8P, 10P, 12AM, 2AM, 4AM, and 6AM on January 10. 3. There was no January 2020 MEMORY CARE ROUND LOG for resident 1, to show rounds had been completed as required.
Plan of Correction:	1. The Call Bell Rating Form was removed from current resident charts and rounds will be periodically done while residents are awake and every two hours while asleep and documented. Administrator and/or designee will monitor a minimum of weekly to ensure compliance is met. Date to be corrected: 2/5/2020 2. A new tracking method of daily rounding logs was implemented, and Administrator and/or designee will monitor a minimum of weekly to ensure compliance is met. The RCC held a meeting with direct care staff on duty 1/16/2020, the on-coming shift on 1/17/2020 and remaining direct care staff on 1/23/2020 and re-educated them on importance and requirements of signing this log during the night shift and will be checked a minimum of weekly by Administrator and/or designee for accuracy. Date to be corrected: 2/5/2020 3. Resident #1 rounding log was in the Memory Care Round logbook behind another resident?s log the evening of inspection. Administrator and/or Designee will audit the memory care rounding logbook a minimum of weekly to ensure all resident?s round sheets are present in logbook. Date to be corrected: 1/16/2020
Standard #:	22VAC40-90-40-B
Description:	Based on review of staff record, the facility failed to ensure that staff?s criminal history record report was obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The date of hire for staff 3 was 08/20/2019 and the criminal history record report for staff 3 was not obtained until 10/10/2019.
Plan of Correction:	1. A criminal record report was in employee?s file from previous employment. A new criminal record will be obtained on or prior to the 30 th day of employment for each employee. Administrator and/or designee will audit all new employee charts a minimum of monthly to ensure compliance is met. Date Corrected: 1/16/2020