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. 31, 2022 , Feb. 9, 2022 and March 18, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 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:

The licensing inspector (LI) for Carriage Hill Retirement, in conjunction with another LI conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 01/31/2022. The LI also conducted two additional on-site inspections; on 02/09/2022 with local adult protective services and on 03/18/2022 with the local long-term care ombudsman. The LIs, adult protective services and the local long-term care ombudsman reviewed resident records, toured the facility, and conducted staff and resident interviews relating to allegations of resident files not being treated confidentiality, multiple resident deaths, resident care and related services, lack of direct care staff, a resident that had an overdose, special diets not being served, lack of housekeeping throughout the facility that included residents' rooms, and staff scheduled to work on 12/24-25/2021 who were not direct care staff trained but were scheduled to provide care to residents. The two licensing inspectors had a preliminary exit interview with the Administrator on 01/31/2022 and the inspector of record for the facility conducted a final exit interview with the Administrator via phone on 04/11/2022 where the violations were reviewed and an opportunity was given to ask questions and provide any additional information. The information gathered during the investigation supports four of the allegations. Additional violations were cited that were not related to the allegations that were reported and can be found on the violation notice. 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 #:	22VAC40-73-1020-A
Complaint related:	Yes
Description:	Based on staff interview and facility document review, the facility failed to ensure that when residents are present, there are at least two direct care staff members awake and on duty at all times in each building who are responsible for the care and supervision of the residents. EVIDENCE: 1. The facility serves a mixed population in the assisted living building of the facility based on document review meaning that there would be to be at least two direct care staff on duty at all times. 2. Interview with staff 2 revealed that staff 6 worked from 9:00pm until 11:00pm and staff 7 worked from 11:00pm until 5:00am; however, neither staff 6 or 7 are trained or certified in providing direct care to residents. Staff 2 confirmed that during the night shift on 12/24/2021 from 9:00pm until 5:00am on 12/25/2021 that there was only one direct care staff member, staff 8, on duty in the facility?s assisted living building.
Plan of Correction:	There was a COVID outbreak among staff around this time and management staff members stepped up during this time frame to assist in covering the building. The licensing inspector is aware of COVID outbreak during this time. Moving forward, we have communicated with external agencies so that in the event that we have another outbreak, or instance where we are short on staffing, we have appropriate care staff available to assist us. We have also hired additional staff members and DON. The DON and administrator will ensure the facility is within limit of compliance moving forward.
Standard #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on review, the facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or that threatened the life, health, safety, or welfare of any resident. EVIDENCE: 1. The record for resident 5 contained hospital discharge documentation, dated 01/11/2022, that the resident had been admitted to the hospital on 01/10/2022 and was being discharged back to the facility. The hospital discharge documentation stated that the resident had ?been evaluated and treated for accidentally taking too much of a medicine, using someone else?s medicine by mistake, or swallowing a chemical product.? 2. Also, a staff progress note for resident 5 written by staff 2, dated 01/29/2022 at 10:34AM, stated that the resident had asked to be sent out to the hospital around 2:30AM and that the hospital had reported to staff 2 that the resident had ?to [sic] much Hydromophone [sic] in his system.? 3. The aforementioned information regarding resident 5 was not reported to the regional licensing office for either instance.
Plan of Correction:	The incident involving residents was reported to licensing. Our administrator is aware of the regulations regarding reportable incidents and will continue to report what meets criteria to report to appropriate licensing agencies.
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 plan (ISP) included all required components. EVIDENCE: 1. Resident 5 was admitted to the facility on 09/23/2021 per staff 1. The record for resident 5 contained a ?Resident-Personal/Social Data? sheet. Interview with staff 7 revealed that the document ?Resident-Personal/Social Data? for resident 5 was completed by Collateral 1 on the resident?s date of admission. On page 2 of 2, Collateral 1 had indicated that the resident did have a substance abuse history and documented the following: ?Overdosed on own meds 4+ times alcohol abuse (stole alcohol from me) cigarette smoking napping (chain smoking)? 2. Documentation from Collateral 7, dated 05/05/2020, included the following information: ?Problem list/past medical history ? ongoing ? overdose and substance abuse?. 3. The aforementioned information listed on the resident?s ?Resident-Personal/Social Data? sheet was not documented on either of the resident?s comprehensive ISPs dated 09/22/2021 and 10/22/2021. Interview with staff 2 on 02/09/2022 revealed that she completes the ISPs it was the first time that she had seen the ?Resident-Personal/Social Date? sheet that was in the resident?s record.
Plan of Correction:	The resident ISP was updated to reflect appropriate resident history. A care plan coordinator consultant was hired to audit the care plans and assist us with compliance ongoing to ensure better documentation, consistency and compliance.
Standard #:	22VAC40-73-560-E
Complaint related:	Yes
Description:	Based on observation and staff interview, the facility failed to keep all resident records in a locked area. EVIDENCE: At approximately 9:09 AM during on-site inspection on 01/31/2022, two licensing inspectors observed the door to the outside white shed by the kitchen loading dock to be unlocked. Inside the unlocked white shed, there were multiple bankers? boxes that contained resident information. Interview with staff 1 confirmed that the boxes did contain resident records.
Plan of Correction:	The shed was secured with a new lock. Maintenance and administration will ensure these records are kept locked to maintain confidentiality of applicable information.
Standard #:	22VAC40-73-610-B
Complaint related:	Yes
Description:	Based on observation and staff interviews, the facility failed to ensure that the current week?s menu was posted in an area conspicuous to residents. EVIDENCE: 1. At 7:39am on 01/31/2022 it was observed that the current week?s menu was not posted on the facilities memory care unit. An interview with staff 3 and 4 it was expressed that the menu is usually posted in the enclosed board beside the kitchen window but it was not posted at the time of this inspection. 2. At 8:26am 0n 01/31/2022 it was observed that the menu that was posted in the dining room of the Assisted Living building was dated 01/23/2022 through 01/29/2022. The current week?s menu was not posted. During the preliminary exit with staff 1 on 01/31/2022 it was expressed that the current menu was posted in the kitchen. This posting is not conspicuous to residents as the doors to the kitchen are locked and residents to not have access into the kitchen.
Plan of Correction:	The menu for the appropriate week was posted immediately. A new dining services director was hired and has been trained on compliance and the weekly posting of the menus.
Standard #:	22VAC40-73-650-F
Complaint related:	No
Description:	Based on resident record review and collateral interview, when a resident was admitted to a hospital for treatment of any condition the facility failed to ensure that the primary physician was aware of any new medication orders and treatments and had documented any contact with the physician regarding the new orders that were obtained at the time of the resident?s return to the facility. EVIDENCE: 1. ?History and Physical? document for resident 5, dated 10/04/2021, by Collateral 2 indicated the following: ?Pain management: I have told him that all pain prescriptions and directions for pain medications through [sic] (Collateral 3). He will be seen a minimum of every 3 months. His reservoir for the morphine pump will need to be refilled. I have deferred changing his Dilaudid to (Collateral 3).? 2. Phone interview with a representative from Collateral 3?s office on 03/30/2022 revealed that they did not receive information from Carriage Hill Retirement regarding the resident?s hospitalization on 01/10/2022 and discharge from the hospital on 01/11/2022 in regards to the new medication orders from the hospital.
Plan of Correction:	Staff has been educated on the importance of notifying all appropriate agencies and parties when a resident goes to the hospital. A DON was hired in an effort to evaluate our nursing team and provide leadership to our healthcare staff. She will oversee documentation and communication related to all incidents and hospitalizations.
Standard #:	22VAC40-73-670-1
Complaint related:	Yes
Description:	Based on review, the facility failed to ensure that a staff person who administers medications is authorized by 54.1-3408 of the Virginia Control Act. EVIDENCE: 1. During on-site inspection on 01/31/2022, staff 3 confirmed that she is a licensed registered medication aide and the staff member administering medications in the facility?s safe, secure unit on this date. According to the Virginia Department of Health Profession License Lookup website, staff 3?s license as a registered medication aide expired on 12/31/2021. 2. The January 2022 medication administration record (MAR) for resident 10 contained initials that staff 5 administered medications to the resident at 8AM on 01/06/2022, 01/08-09/2022, 01/14/2022, 01/19-20/2022, and 01/22-23/2022. According to the Virginia Department of Health Profession License Lookup website, staff 5?s license as a registered medication aide expired on 12/31/2021.
Plan of Correction:	Staff #3?s license has been updated and reinstated. HR has been educated on auditing this timely and new procedures have been put in place to ensure compliance with this.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on resident interview, staff interviews and photo evidence, the facility failed to ensure medications were administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. The record for resident 5 contained a public pay uniform assessment instrument (UAI), dated 09/14/2021, that indicated the resident can take medications without assistance; however, the individualized service plan (ISP) dated 09/22/2021, indicated that for medication administration the resident?s medications will be ?administered by lay person: med tech ? a registered medication aide/nurse will administer medications per MD orders to resident. RMA/Nurse will ensure all meds were taken and swallowed before exiting room.? Phone interview with staff 2 on 03/28/2022, revealed that the resident does need assistance with medication administration and that the UAI is incorrect. 2. The UAI for the resident indicates that the resident is oriented and the two ISPs, dated 09/22/2021 and 10/22/2021, indicate that the resident is oriented x4 and alert and oriented to all spheres. 3. Regarding the duties of registered medication aides (RMAs) when providing assistance with oral medication administration, section 4.2 of the Commonwealth of Virginia Board of Nursing Medication Aide Curriculum for Registered Medication Aides, revised 05/21/2013, pages 122-123 state the following: ?11. Stay with the client until he/she has swallowed the medications (check mouth PRN).? 4. The record for resident 5 contained a physician?s order, dated 10/04/2021, for the following scheduled 8:00PM medications: Amitiza, Ibuprofen, Pregabalin, Prazosin, Topiramate and Trazodone. During interview with resident 5 on 03/18/2022, resident 5 revealed that the 7PM-7AM registered medications aides (RMAs) would bring him his scheduled 8:00PM medications (pills) in a souffle cup prior to his hospitalization on 01/10/2022; however, the medication staff would leave the pills with him and would leave the room without observing him taking the medications (pills). Resident 5 stated specifically that he did not wish to take the whole schedule 8PM trazodone pill and he would cut the whole pill into four pieces and take one piece at a time prior to going to sleep. 5. The licensing inspector (LI) was provided photo evidence by Collateral 1 of pills that were found in the resident?s room on 01/07/2022 by Collateral 1. Resident 5 confirmed during interview on 03/18/2022 that the pills in the two photos were the pills that were found in his room by Collateral 1 on 01/07/2022. Resident 5 verified that the medications in the two pictures included multiple Trazadones, two Acetaminophen (physician?s order dated 10/29/2021 for APAP 500 mg every 12 hours PRN (as needed), two Dilaudid (physician?s order dated 10/04/2021 for Hydromorphone/Dilaudid 2 MG one tablet four times a day), one Baclofen (physician?s order dated 09/23/2021 Baclofen 20MG take one tablet twice daily PRN (as needed) for muscle spasms), one Synthroid (physician?s order dated 10/04/2021 take one tablet every morning), and one Iron (physician?s order dated 10/04/2021 for Ferrous Sulfate take one tablet every Monday, Wednesday and Friday for supplement) and were his prescribed medications. Phone interview with staff 10 revealed that the resident did have an issue with ?hoarding medications? and that she had found medications in the resident?s room prior to Collateral 1?s findings on 01/07/2022. Staff 10 stated that she sent pictures of the pills to staff 1 that she found in the resident?s room and was instructed by staff 1 to dispose of the pills. (violation notice continued on separate document)
Plan of Correction:	Resident UAI and ISP were audited and corrected to reflect the same information RMS?s were educated on Section 4 of the medication aide curriculum and were educated on appropriate practices for administering medications. DON was hired and is reviewing medication management system in the building. She provides on the job training to med techs and is spot checking med passes to ensure proper compliance.
Standard #:	22VAC40-73-700-2
Complaint related:	No
Description:	Based on observation, the facility failed to post ?No Smoking-Oxygen in Use? signs when oxygen therapy is provided. EVIDENCE: Room B20 contained an oxygen concentrator and a portable oxygen tank, room C52 contained an oxygen concentrator, and room D68 contained multiple portable oxygen tanks in the closet. These rooms did have residents residing in them during the on-site inspection on 01/31/2022. These rooms did not contain a ?No Smoking-Oxygen in Use? sign.
Plan of Correction:	No smoking oxygen in use signs have been placed on all applicable resident rooms. Newly hired DON will ensure anyone using oxygen has appropriate signage to ensure compliance.
Standard #:	22VAC40-73-780-B
Complaint related:	No
Description:	Based on observation, the facility failed to ensure that bed linens were changed at least every seven days and more often if needed. EVIDENCE: At approximately 8:47am during on-site inspection, two licensing inspectors observed the flat sheet on the bed in resident 6?s room to be saturated with a yellow substance.
Plan of Correction:	The residents? sheets were changed. Housekeeping schedules are formatted so that all residents? linens are checked daily and are changed as needed, no less than multiple times a week. Our housekeeping director and care team are checking rooms several times a day to ensure compliance with this.
Standard #:	22VAC40-73-860-I
Complaint related:	No
Description:	Based on observation, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area. EVIDENCE: 1. At approximately 8:24 AM during on-site inspection on 01/31/2022, the door to room 56 (employee lounge) in the facility?s assisted living building was found by two licensing inspectors to be unlocked. A container of sani-cloth germicidal disposable wipes and a spray bottle of liquid performance sanitizing spray was found sitting on the table in the employee lounge. 2. At approximately 8:52 AM, the door to room A16 which is also located in the facility?s assisted living building was found to be unlocked and contained an unlocked housekeeping rolling cart that contained a bottle of 401 K organic acid bowl cleaner, a spray bottle of preservation furniture polish and an unmarked clear spray bottle with a light yellow substance.
Plan of Correction:	Both doors were secured while inspectors were on site. Staff has been educated that no chemicals of any kind should be left unattended in an unsecured environment. Housekeeping has been notified of this and does audits daily to ensure compliance.
Standard #:	22VAC40-73-870-A
Complaint related:	Yes
Description:	Based on observation and staff interviews, the facility failed to keep the interior of the building clean. EVIDENCE: 1. Between 8:15am and 8:58am during on-site inspection on 01/31/2022 multiple dried stains and drag marks were observed down the hallways of the A, B, C and D units. Spots that were wet with a brown substance were observed in the hallway outside of rooms A2, B27 and C48. Interviews with staff expressed that the stains and drag marks were caused by some employees dragging bags of trash down the hallways. 2. At approximately 8:29am, two licensing inspectors observed a large spill of liquid beside the resident?s bed in room C52. 3. The floor around the toilets in the bathrooms of rooms C52 and A3 contained a sticky substance around the bottom of the toilets.
Plan of Correction:	Hallways have been touched up with paint and have been patched and repaired. Staff has been educated on proper trash removal and housekeeping procedures verified to enter compliance with keeping rooms clean.
Standard #:	22VAC40-73-870-B
Complaint related:	No
Description:	Based on observation, the facility failed to ensure all buildings were well-ventilated and free from foul, stale, and musty odors. EVIDENCE: Between 8:29am and 8:47am during on-site inspection on 01/31/2022, there was a strong scent of urine in rooms A1, A3 and C52.
Plan of Correction:	Residents had just woken up this morning. They were changed and cleaned before breakfast and housekeeping was present per normal schedule to evaluate laundry, and linens and transfer appropriate clothing and linens to be washed. This was noted within an 18 minute time period, and while residents were waking up.
Standard #:	22VAC40-73-930-D
Complaint related:	No
Description:	Based on document review, the facility failed to document that rounds were made for each resident with an inability to use a signaling device which included the date, time, and staff member who made the rounds. EVIDENCE: The "Memory Care Rounding Log" documents for November and December 2021 and January 2022 for the hours of 12AM through 6AM provided to the licensing inspector (LI) by staff 2 on 01/31/2022 for the facility's safe, secure building residents who have an inability to use a signaling device contained multiple dates and times that did not contain the signature of a staff member that rounds were made for multiple residents.
Plan of Correction:	The Memory care rounds are documented in two locations: EMAR and paper documentation. The facility will transition completely into two-hour rounds on EMAR for its 24 hours round documentation. The DON will monitor compliance in this regard.