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 18, 2022

Complaint Related: Yes

Areas Reviewed:

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

Comments:

The licensing inspector (LI) for Carriage Hill Retirement conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 03/18/2022 in conjunction with the local long-term care ombudsman. The LI reviewed documentation and conducted interviews with staff and one resident relating to allegations of an inappropriate discharge notice and a staff member identified as in charge not being trained on their duties while in charge. The LI had a preliminary exit interview with the Administrator during the on-site inspection on 03/18/2022 and a final exit interview via phone on 03/28/2022 where an opportunity was given to ask questions regarding the violations. The information gathered during the investigation supports the allegations. Based on the preponderance of evidence the complaint is determined to be valid. 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. If you have any questions, contact your licensing inspector at (540) 589-5216.

Violations:

Standard #:	22VAC40-73-190-C
Complaint related:	No
Description:	Based on staff record review, the facility failed to ensure that the staff member, prior to being placed in charge, was informed of and received training on his duties and responsibilities and provided written documentation of such duties and responsibilities. EVIDENCE: 1. The licensing inspector (LI) was informed by Collateral 2 that on 03/16/2022 she visited the facility to speak with staff 1. Collateral 2 was informed by facility staff that staff 1 was not present and that staff 3 was in charge. Interview with staff 1 confirmed that staff 3 was in charge on 03/16/2022 during his absence from the facility. 2. Staff 1 provided the LI the record for staff 3 during on-site inspection on 03/18/2022. The record for staff 3 did not contain written documentation that staff 3 had been informed of and received training on her duties and responsibilities prior to being placed in charge.
Plan of Correction:	Staff was trained to be supervisor-in-charge, but no credit hours was assigned to the training. Facility will ensure credit due to this training is allotted to it per first desk reviewer?s suggestions.
Standard #:	22VAC40-73-430-B
Complaint related:	No
Description:	Based on document review, the facility failed to ensure that as soon as discharge planning beings, the resident was notified of the reason for the discharge. EVIDENCE: 1. The discharge notice, dated 03/02/2022, for resident 1 contained the following: ?The facility has activated its 30 days discharge notice policy for (resident 1) on 03/02/22 due to facility?s inability to meet resident?s needs.? The notice did not identify which needs of the resident that the facility cannot meet.
Plan of Correction:	Facility will no longer use `unable to meet resident needs? as the reason for discharge. Moving forward, facility will ensure that reason(s) for discharge is specifically described.
Standard #:	22VAC40-73-560-F
Complaint related:	No
Description:	Based on observation, the facility failed to ensure all records were treated confidentially and that information is made available only when needed for care of the residents. EVIDENCE: 1. During on-site inspection on 03/18/2022 at approximately 1:00PM, the licensing inspector (LI) observed that the computer located on top of medication cart B was left unlocked allowing any individual to access information regarding residents and their medications. The LI noted that there were no staff members around the medication cart. The LI informed staff 1 of this observation and staff 1 confirmed this was accurate and proceeded to lock the information on the computer. Staff 1 stated that staff 2 was the registered medication aide (RMA) that currently had possession of the keys to medication Cart B and also noted that staff 2 nor any other staff were located near the medication cart. Also, the LI noted that the small trash container located on the side of medication cart B contained an empty blister pack for resident 2 for methotrexate 2.5MG and resident 3 for true metrix glucose strips. The resident information had not been marked out by staff prior to being placed in the trash container. This was also observed by staff 1.
Plan of Correction:	Computer screen was immediately locked and name on the empty medicine container was scratched. Staff member was educated with medication management standards. DON had an in-service with staff on medication management plan. DON or designee will conduct medication cart rounds to ensure compliance and privacy. Education consultant will also routinely aduit when visiting.
Standard #:	22VAC40-73-660-A
Complaint related:	No
Description:	Based on observation, the facility failed to ensure that when medications and dietary supplements are administered by the facility, the medicine container that is used for storage of medications and dietary supplements prescribed for residents was locked. EVIDENCE: During on-site inspection on 03/18/2022 at approximately 1:00PM, the licensing inspector (LI) observed medication cart B located on B hall outside of staff 1?s office to be unlocked and no staff were observed near the cart by the LI. When staff 1 was alerted of this, the LI observed staff 1 lock the cart by pushing in the lock and staff 1 revealed to the LI that the cart was unlocked and unattended. Staff 1 stated that staff 2 was the registered medication aide (RMA) that currently had possession of the keys to medication Cart B; however, the LI and staff 1 observed that staff 2 was not located near medication cart B and had left the cart unlocked and unattended.
Plan of Correction:	Medication cart was locked immediately. Staff member was educated with medication management standards. DON had an in-service with staff on medication management plan. DON or designee will conduct medication cart rounds to ensure compliance and privacy. Education consultant will also routinely audit when visiting.
Standard #:	22VAC40-73-680-B
Complaint related:	No
Description:	Based on observation, the facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label attached, until administered to residents. EVIDENCE: During on-site inspection on 03/18/2022, the licensing inspector (LI) observed two small, round pills with an inscription of HH210 lying on the floor outside of room 23 on B hall of the facility. The pills were also observed by staff 1 and Collateral 1.
Plan of Correction:	Loose pills were properly disposed per facility policy. Nursing and housekeeping staff were instructed to monitor and conduct inspection daily and be vigilant to any possible loose pills and report to Resident Care Coordinator and DON.