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: March 1, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION.

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 complaint inspection was initiated on 03/01/2021 and concluded on 03/17/2021. A complaint was received by the department regarding allegations in the areas of admission, retention and discharge of residents. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-320-A
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that within 30 days preceding admission, all residents had a physical examination by an independent physician. EVIDENCE: 1. The record for resident 1, admitted 07/30/2020, did not contain documentation of a physical examination by an independent physician. 2. Interview with staff 1 confirmed that the resident did not have a physical examination by an independent physician preceding admission to the facility.
Plan of Correction:	Admission staff were provided with a copy of State Model Form 032-05-0007-09-eng (02/18) and were educated on the importance of gathering preadmission medical information prior to admission of a resident. Staff were educated on the information gathered on State Model Form and its importance to the admission of prospective residents. State Model Form has been provided to staff in digital and physical format to ensure availability.
Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that the fall risk rating was reviewed and updated after a fall for residents who meet the criteria for assisted living care. EVIDENCE: 1. The record for resident 1 showed that the most recent fall risk rating for the resident was dated 07/24/2020; however, a progress note for resident 1 stated, ?Late Entry for 12/4/2020 5:00 PM: PT returned to facility via transport. Pt returned from hospital with c/o pains in her left jaw, right leg and her left elbow. Pt stated that the fall hurt her pretty bad and that she will be in her room until tomorrow getting some rest.? 2. Interview with staff 1 confirmed that the fall risk rating had not been updated.
Plan of Correction:	Administrator and/or designee will ensure fall risk ratings are completed on each fall and filed accordingly in Resident?s chart.
Standard #:	22VAC40-73-450-F
Complaint related:	No
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 ISP for resident 1, dated 07/29/2020, showed that the resident was ?Abusive/Aggressive/Disruptive ? Less than weekly? and the type of inappropriate behavior was ?Recent ECO to hospital for agitated behavior related to UTI.? The uniform assessment instrument (UAI), dated 07/24/2020, showed that the resident was ?Abusive/Aggressive/Disruptive ? Less than weekly? and the type of inappropriate behavior was ?Recent ECO to hospital for agitation that may be related to UTI.? 2. The most recent UAI for resident 1, dated 09/24/2020 and completed by the local department of social services, showed on page 8 that resident 1 is ?Abusive/Aggressive/Disruptive ? Weekly or more? and the type of inappropriate behavior is ?agitated easily, refuses meds at times? and ?source of information: (staff 2)?. 3. The ISP was not updated to reflect this change in resident 1?s condition.
Plan of Correction:	Community will audit resident charts to ensure ISPs are in line with UAIs and are up to date. Discrepancies will be adjusted to reflect resident?s current needs.
Standard #:	22VAC40-73-460-B
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure prompt response by staff to resident needs as reasonable to the circumstances. EVIDENCE: 1. The record for resident 1 contained a ?psychiatric periodic evaluation?, dated 01/12/2021 and completed by Collateral 1, that stated, ?Patient today is continued to have irritability and refuse medication at times.? and ?Follow-up: Monitor for changes in mood or behaviors. Please contact (Collateral 2) as needed for concerns and consultation.? 2. Resident 1 continued to refuse medications as indicated by progress notes dated 01/22/2021 that resident ?refused all AM and PM medications?; progress notes dated 01/19/2021, 01/23/2021 and 01/26/2021 that resident refused all AM (morning) medications; and progress note dated 01/28/2021 that resident refused all PM (evening) medications. 3. Progress note for resident 1, dated 01/19/2021, stated ?resident was put on the docs list to be seen? and progress note, dated 01/28/2021, stated ?doctor notified?; however, there was no documentation that resident had been seen by a physician or that the facility contacted Collateral 2 as instructed by Collateral 1. 4. The February 2021 medication administration record (MAR) for resident 1 shows that the resident refused to take multiple medications daily from 02/01/2021 through 02/14/2021. A progress note for resident 1, dated 02/15/2021, showed the resident was agitated and pulled out a pair of scissors in a threatening manner on 02/11/2021. A progress note for resident 1, dated 02/15/2021, stated the following, ?Resident has become a danger to herself and others currently that has had escalating behavior for one week.? Hospital documentation, dated 02/15/2021, stated the following, ?Chief Complaint ? (Facility) called us for an ECO because she keeps calling 911 & saying we?re starving her cats & has been threatening to stab us with scissors. She?s refusing all medications.? 5. Resident returned to the facility from the hospital on 02/16/2021 and the February 2021 MAR showed from 02/16/2021 through 02/28/2021 showed that the resident continued to refuse multiple medications on numerous days. 6. Progress note, dated 02/18/2021, showed that staff 3 reached out to Collateral 1 and Collateral 1 refused to see resident and that ?another practitioner would be assuming a new role with the facility and would be there in a few weeks.? Also, the progress note showed that staff 3 reached out to local adult protective services (APS) and APS (Collateral 3) ?agreed Resident was a danger to herself and `especially others? in the facility and agreed Resident `needed to be TDO?d? for stabilization of meds and mental health issues. Instructed to `call 911 immediately when she acts up? and file ECO papers and notify on-call APS worker?. 7. Progress note, dated 02/28/2021 at 1:48 AM, stated that resident 1 had called 911 and spoke with officer alone in her room and ?resident still refusing all meds. resident seems to be seeing things that are not there as she reported to staff there were two people outside window near front of building when nothing nor anyone was there.? 8. Progress note, dated 03/01/2021 at 7:41 AM, stated that ?resident came to staff and told staff that `the man with one leg came in my room with a weapon and said he was going to kill me and my cat??. Additional progress note on 03/01/2021 at 12:39 PM stated that ?staff reported to (Staff 1) that resident accused a resident of coming into her room with a weapon and threatening her. Also progress note on 03/01/2021 at 1:46 PM stated that resident 1 had thrown a glass of water on another resident. 9. Interview with staff 1 revealed that the facility had requested an ECO for resident 1 on 03/01/2021 and resident was sent out of facility on an ECO. Staff 1 stated that resident 1 is currently in an inpatient psychiatric facility.
Plan of Correction:	Facility has trained nursing staff through In-service on: 1. Refusal of Medication 2. Reporting Refusal 3. Follow-up to Refusal