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 25, 2021

Complaint Related: Yes

Areas Reviewed:

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 BUILDING AND GROUNDS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 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 03/25/2021 and concluded on 05/13/2021. A complaint was received by the department regarding allegations in the areas of personnel, admission, retention and discharge of residents, resident care and related services. 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. To ensure that the facility had a thorough understanding of standards, the licensing inspector, Vice President and Administrator had a discussion regarding 440 A, 440 D and 640 A. The evidence gathered during the investigation supported one allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-290-A
Complaint related:	No
Description:	Based on document review and staff interview, the facility failed to maintain a written work schedule with an indication of whomever is in charge at any given time. EVIDENCE: 1. The work schedule provided to the licensing inspector for the time period 03/14/2021 through 03/26/2021 does not indicate which direct care staff was in charge during each shift for this time period. Interview with staff 1 confirmed this information.
Plan of Correction:	1. Facility will indicate on staffing schedule staff member in charge for each shift.
Standard #:	22VAC40-73-440-D
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that the uniform assessment instrument was completed as required. EVIDENCE: 1. The UAI for resident 9, dated 03/11/2021, showed that the resident is ?disoriented ? some spheres, all the time?; however, the UAI does not indicate which spheres are affected. Interview with staff 1 revealed that the spheres affected are time and place.
Plan of Correction:	1. Facility will ensure UAI indicates spheres affected and documented accordingly.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that the individualized service plans (ISP) included all required components. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 5, dated 03/19/2021, stated that the resident needs physical assistance with bathing and supervision with toileting. The ISP for resident 5, with an identified need date of 03/19/2021, showed the resident needs supervision with bathing and does not need any assistance with toileting. Interview with staff 1 revealed that the UAI is incorrect and the ISP is correct. 2. The UAI for resident 6, dated 03/15/2021, stated on page 7 that resident is allergic to influenza vaccine and pneumococcal vaccine. This is not documented on the resident?s ISP. 3. The UAI for resident 9, dated 03/11/2021, stated that the resident needs physical assistance only with stairclimbing. The ISP for resident 9, dated 03/12/2021, showed that the resident needs physical assistance and mechanical assistance (hand rails) with stairclimbing. Interview with staff 1 revealed that the UAI is incorrect and the ISP is correct.
Plan of Correction:	1. Care Plan Coordinator and or Director of Nursing will ensure initial UAI /ISP needs align and is documented.
Standard #:	22VAC40-73-460-I
Complaint related:	No
Description:	Based on document review, the facility failed to ensure that all residents are dressed in clean clothing. EVIDENCE: 1. Two photographs, provided by Collateral 2, dated 03/19/2021 at 1:14 PM, showed resident 1 wearing a stained shirt. There was also food on his shirt and pants. See (ALF11041416 03-19-21 P2) and (ALF11041416 03-19-21 P3) attached. 2. Interview with staff 1 on 05/13/2021 confirmed that resident 1 needs assistance with changing his clothes.
Plan of Correction:	1. Resident physician was notified of needed order for bibs. Staff instructed to provide resident with bibs during meals.
Standard #:	22VAC40-73-460-J
Complaint related:	Yes
Description:	Based on documentation review, the facility failed to ensure that all residents who are incontinent have clean clothing and linens each time their clothing or bed linen is soiled or wet. EVIDENCE: 1. The individualized service plan (ISP) for resident 2, dated 02/11/2021, stated that the resident has bladder incontinence, with expected outcomes/goals ?Resident will be clean, dry & free of odor and Skin integrity will be maintained?. The ISP also states that the resident needs physical assistance with dressing. 2. Interview with Collateral 4 on 03/24/2021 revealed when Collateral 4 came to the facility on 03/18/2021 to visit with resident 2 that the resident?s clothing and linens were soaked with urine; however, the resident?s brief had been changed. 3. Interview with staff 1 confirmed that staff 2 was terminated by the facility because staff 2 admitted to not changing the resident?s clothes and linens when she changed the resident?s brief. Staff 1 confirmed that resident 2 needs staff assistance with changing her clothes and linens.
Plan of Correction:	1. Staff member was terminated, hospice provider was contacted and requested for additional service days, and Administrator reviewed with staff changing of briefs and linens when soiled.
Standard #:	22VAC40-73-480-E
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that the evaluations of progress and other pertinent information regarding rehabilitative services shall be recorded in the resident?s record. EVIDENCE: 1. The licensing inspector (LI) requested home health notes from November 2020 until present for resident 8 on 04/13/2021. Staff 1 informed the LI that the home health notes had to be requested from the home health agency on 04/13/2021 as the notes were not in the facility.
Plan of Correction:	1. Facility requested home health deliver notes after visits and check out with Director of Nursing post visit.
Standard #:	22VAC40-73-580-F
Complaint related:	No
Description:	Based on resident record review, the facility failed to notify resident?s attending physician when a significate weight loss of 5.0% in one month was identified. EVIDENCE: 1. The record for resident 7 contained documentation that the resident weighed 242 lbs. on 07/05/2020 and 228 lbs. on 08/05/2020 which is greater than a 5% weight loss in one month. 2. The record for resident 7 did not contain documentation that the resident?s attending physician was notified of the weight loss.
Plan of Correction:	1. Director of Nursing will oversee resident weights and ensure changes over 5% are reported to the resident?s physician and documented in the resident?s chart.
Standard #:	22VAC40-73-650-A
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment was discontinued without a valid order from a physician of other prescriber. EVIDENCE: 1. The uniform assessment instrument completed by Collateral 6, dated 03/15/2021, included current physician?s orders that included ?diphenhydramine (Benadryl) 25 mg = 1 cap, Oral, Tab, every 6 hr for 365 days, PRN pain?. 2. The March 2021 medication administration record (MAR) for resident 6 did not contain this medication and the resident?s record did not contain a discontinued order for this medication.
Plan of Correction:	1. Facility contacted pharmacy and clarified current prescribed medications. Medications discontinued were documented in the MAR and an order placed in chart.
Standard #:	22VAC40-73-870-A
Complaint related:	No
Description:	Based on document review, the facility failed to ensure that the interior of all buildings are maintained in good repair and kept clean. EVIDENCE: 1. A photograph, provided by Collateral 1, dated 04/28/2021, showed two cracked floor tiles at the entry way of C hallway. See (ALF11041416 04-28-2021 P1) attached. 2. Video with audio, provided by Collateral 1, dated 04/28/2021, showed Collateral 1 walking down the hallway on C Wing. The audio supported Collateral 1's report that the floor was sticky "all the way down the hall beside the kitchen".
Plan of Correction:	1. Facility replaced tiles and changed moping solution from hospital grade disinfectant (COVID-19) to all-purpose moping solution.
Standard #:	22VAC40-73-870-E
Complaint related:	No
Description:	Based on document review, the facility failed to ensure that all furnishing were kept clean and in good repair and condition. EVIDENCE: 1. Two photographs provided by Collateral 1 showed that on 04/28/2021 the floor around the toilet in resident 3's room had not been cleaned. See (ALF11041416 04-28-21 P4) and (ALF11041416 04-28-21 P5) attached. 2. Photograph provided by Collateral 1, dated 03/26/2021, of the toilet in resident 4's room showed a brown substance, that appeared to be feces on the toilet. See (ALF11041416 03-26-21 P6) attached. Photograph provided by Collateral 1, dated 04/28/2021, showed the toilet in resident 4's room had a brown substance that appeared to be feces on the seat and what appeared to be urine in the toilet where the toilet had not been flushed. See (ALF11041416 04-28-21 P7) attached. 3. Photograph provided by Collateral 1, dated 03/26/2021 at 12:17 PM, showed three lines of a brown substance, that appeared to be feces on the side of the box spring for the mattress for resident 4 that had not been cleaned. See (ALF11041416 03-26-21 P8) attached. Additional photographs from 03/29/2021 at 1:19 PM from Collateral 1 showed that the three lines of brown substance had not been completely cleaned from the box spring. See (ALF11041416 03-26-21 P9) and (ALF11041416 03-26-21 P10) attached.
Plan of Correction:	1. Incontinent needs addressed with nursing staff / housekeeping, box spring replaced, and waterproof cover installed.
Standard #:	22VAC40-73-930-D
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure that for each resident with an inability to use a signaling device, the facility shall document rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. EVIDENCE: 1. Resident 5 was admitted to the facility on 03/15/2021. The individualized service plan (ISP) for resident 5, with an identified need date of 03/15/2021, showed ?CALL BELLS Resident is not able to alert staff when assistance is needed? and ?Resident is unable to use call bell to alert staff when assistance is needed, and staff will check on and document a minimum of every 1 hour while asleep and every 2 hours while awake. Staff will assess a minimum of annually and/or if a significant change or as needed.? The record for resident 5 did not contain documentation of the times rounds were made on the resident from 03/15/2021 through 03/30/2021. The record for resident 5 only includes that rounds were made at 4PM, 6PM, 8PM and 10PM on 03/31/2021. 2. Resident 6 was admitted to the facility on 03/18/2021. The ISP for resident 6, with an identified need date of 03/18/2021, showed ?CALL BELLS Resident is not able to alert staff when assistance is needed? and ?Resident is unable to use call bell to alert staff when assistance is needed, and staff will check on and document a minimum of every 1 hour while asleep and every 2 hours while awake. Staff will assess a minimum of annually and/or if a significant change or as needed.? The record for resident 6 does not contain documentation of the times rounds were made on the resident from 03/18/2021 through 03/30/2021. The record for resident 6 only includes that rounds were made at 4PM, 6PM, 8PM and 10PM on 03/31/2021.
Plan of Correction:	1. Director of Nursing will ensure staff complete rounds and document accordingly.