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: Oct. 8, 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 32.1 Reported by persons other than physicians 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 SANCTIONS.

Technical Assistance:

To ensure the facility had a thorough understanding of standards, the LI and the Administrator had a discussion regarding standards 440 A, 450 E and 450 C.

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 10/07/2020 and concluded on 10/08/2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 57; 43 residents in assisted living & 14 residents in the special care unit (SCU). The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, the staff schedule for the past two weeks, recent health care oversight, recent health department inspection, and fire and emergency drills for the past three months submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-440-D
Description:	Based on resident record review and staff interview, the facility failed to complete the Uniform Assessment Instrument (UAI) as required. EVIDENCE: 1. The private pay UAI for resident 3, dated 02/28/2020, showed the resident is ?disoriented ? some spheres, some of the time? and ?spheres affected: Date?. The Individualized Service Plan (ISP), dated 03/03/2020, showed ?ORIENTATION Disoriented to: Time Some spheres, some time?. Interview with staff 5 revealed that the ISP is correct and the UAI assessment is incorrect.
Plan of Correction:	1. The UAI for resident 3 was updated to reflect the same orientation status as resident 3?s ISP. 2. Resident Care Coordinator and Administrator reviewed the importance of ensuring consistent documentation between the UAI and ISP to make sure that both documents are reflective of the same information. 3. Since this incident, a new Resident Care Coordinator and Administrator have started in the building. 4. The Resident Care Coordinator and Administrator will review UAI?s and ISP?s at random no less than monthly to ensure that all documentation on both forms are consistent.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to ensure that individualized service plans (ISP) were reviewed and updated as the condition of a resident changes. EVIDENCE: 1. The record for resident 1 contained staff notes that showed the resident had 10 falls between 08/13/2020 through 09/21/2020. The current ISP for resident 1 showed that the resident is a fall risk; however, the ISP had not been updated since 07/30/2020 in regards to the resident?s falls to show interventions that staff had put into place to prevent subsequent falls for resident 1.
Plan of Correction:	1. The ISP for resident 1 was updated to reflect appropriate fall interventions. 2. Resident Care Coordinator was educated on the importance of ensuring all fall interventions for all residents are documented appropriately and are updated timely on the ISP. 3. No less than monthly, the Resident Care Coordinator will review all resident incidents to ensure (as appropriate) all interventions are in place and are documented on resident ISP and UAI. 4. No less than quarterly, Administrator will review UAI?s and ISP?s to make sure all documentation for fall interventions has been updated and reflects current status of the resident. In routine meetings between Resident Care Coordinator and Administrator, updates for fall interventions will be discussed.
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review, the facility failed to ensure a valid physician?s order for oxygen contained all the required components. EVIDENCE: 1. The record for resident 2 contained a physician?s order, dated 09/11/2020, that showed ?OXYGEN (O2) ? NASAL CANNULA ? USE 2 TO 4L OXYGEN VIA NC DAILY AS NEEDED FOR SHORTNESS OF BREATH?. The order does not contain the oxygen source.
Plan of Correction:	1. The record for resident 2 has been updated to reflect the order for the source of oxygen to read ?via nasal cannula per oxygen concentrator?. 2. This resident is on hospice. Administrator spoke with the treating hospice team regarding this violation and educated them on the importance of making sure that all physicians orders are thorough, and documentation in the residents record reflects complete physician orders. 3. Carriage Hill?s healthcare team will review all new orders for all patients on hospice with the hospice healthcare team at monthly healthcare meetings. 4. Carriage Hill?s healthcare team will review all new resident orders from hospice team in resident records no less than monthly to ensure orders are complete.