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: April 28, 2022

Complaint Related: No

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 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 22VAC40-90 The Criminal History Record Report

Comments:

The licensing inspector (LI) for Carriage Hill Retirement, along with another LI and under the supervision of the licensing administrator (LA), conducted an unannounced, non-mandated inspection on 04/28/2022 from 9:00AM until 2:30PM, finding 60 residents in care. This inspection is the first of two inspections for the facility?s Provisional license. The LIs and the LA reviewed high risk violations that were cited at the facility?s renewal inspection on 11/30/2021 as well as any high risk violations that have been cited this licensure year. A tour of the physical plant for both the assisted living building and the safe, secure building were conducted, four medication carts were audited, resident records were reviewed, four staff trainings were reviewed, criminal record checks for staff hired and staff employed since 12/01/2021 were reviewed and staff and resident interviews were conducted. Findings were reviewed with facility staff during the inspection. A preliminary exit interview was conducted with the Administrator, the Director of Nursing and the Regional Director on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. A final exit interview was held with the Administrator on 04/29/2022 via phone. 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 #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure that physical examination reports for residents contained all required components. EVIDENCE: 1. The ?Report of Resident Physical Examination? for resident 1, dated 08/18/2021, did not contain the resident?s height. The examination also indicated that the resident has an allergy to Voltoren; however, there is no description of the resident?s reactions. 2. The ?Report of Resident Physical Examination? for resident 2, dated 03/11/2022, did not contain information on whether or not the resident is capable of self-administering medication and it also did not contain the resident?s address and telephone number. 3. The ?Report of Resident Physical Examination? for resident 3, dated 11/05/2021, and resident 4, dated 01/25/2022, did not contain the address and telephone number of the residents.
Plan of Correction:	The residents height has been added to the Physical, and reactions to the medication have been updated as well. The appropriate residents telephone number and address have been updated. The appropriate physical form has been updated in all resident charts. An audit has been performed to ensure that all physical?s have been filled out completely. DON and resident care coordinator in addition to our compliance consultants will be auditing routinely to ensure compliance.
Standard #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to ensure that resident personal and social information contained all required components. EVIDENCE: 1. The ?Resident ? Personal/Social Data? document for resident 1, admission date 08/19/2021, did not indicate if the resident had served in Armed Forces and did not include documentation of the resident?s strengths. 2. The ?Resident ? Personal/Social Data? document for resident 2, admission date 03/16/2022, did not include documentation regarding the resident?s current behavioral and social functioning. 3. The ?Resident ? Personal/Social Date? document for resident 3, admission date 11/18/2021, did not indicate if the resident had served in Armed Forces and did not include documentation of the resident?s current behavioral and social functioning.
Plan of Correction:	The resident?s personal social data forms have been updated to reflect all required and appropriate information. Our Admissions department has been educated and taught about the proper completion of Admission documents including the personal social data form. Our Regional Marketing Director in addition to our resident care coordinator and compliance consultants have audited resident charts to ensure this form has been completed appropriately for all current residents. Moving forward our team has been trained to appropriately fill out this form to ensure compliance.
Standard #:	22VAC40-73-640-A
Description:	Based on document review, the facility failed to implement their medication management plan. EVIDENCE: 1. The facility?s medication management plan states ?at the end of each shift, the outgoing and incoming RN, LPN, or RMA authorized to administer medications, will count all controlled substances and sign the Controlled Medication Log verifying the count is accurate.? 2. At approximately 9:23AM on 04/28/2022 during on-site inspection, the ?Shift to Shift Narcotic Count Sign Off Sheet? for medication cart A for April 2022 did not contain the signature of the medication staff coming on duty (11p-7a) for 04/27/2022 and (7a-3P) for 04/28/2022 and did not contain the signature of the medication staff going off duty (11p-7a) for 04/28/2022. 3. At approximately 9:22AM on 04/28/2022 during on-site inspection, the ?Shift to Shift Narcotic Count Sign Off Sheet? for medication cart B for April 2022 did not contain the signature of the medication staff coming on duty (11p-7a) for 04/27/2022. 4. At approximately 9:38AM on 04/28/2022 during on-site inspection, the ?Shift to Shift Narcotic Count Sign Off Sheet? for medication cart C for April 2022 did not contain the signature of the medication staff coming on duty (7p-3p) for 04/28/2022. 5. At approximately 10:11AM on 04/28/2022 during on-site inspection, the ?Shift to Shift Narcotic Count Sign Off Sheet? for medication cart E for April 2022 did not contain the signature of the medication staff coming on duty (11p-7a) for 04/27/2022.
Plan of Correction:	Our medication management plan has been updated to reflect the oversight and management by our DON that is being completed. We have reviewed the policy with our medication technicians and nurses, and they are aware of our standard as it relates to narcotic logs. Ongoing, our DON and staff will be checking narcotic counts daily, and will be counting off daily to ensure that the narcotic counts for our residents are accurate and accounted for. We will perform random spot checks to ensure this is being completed accurately and according to our medication management policy.
Standard #:	22VAC40-73-680-B
Description:	Based on observation during a tour of the facility?s memory care building, the facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to residents. EVIDENCE: During on-site inspection on 04/28/2022, two licensing inspectors observed two round, white pills in resident 6?s room. These pills were also observed by staff 1 in the resident's room.
Plan of Correction:	Medication technicians have been educated on the medication management policy and appropriate storage and distribution of medications. DON is making daily rounds during and after med pass times to ensure that meds are administered and stored properly.