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: June 13, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 06/13/2022 from 9:00AM until 5:30PM. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication passes, noon-time meal in the facility?s assisted living building, medication cart audits for four medication carts in the facility?s assisted living building and one medication cart in the facility?s safe, secure unit. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-C-2
Description:	Based on observation during medication cart audit, the facility failed to ensure that infection control policies that are consistent with the Centers for Disease Control and Prevention (CDC) recommendations were followed. EVIDENCE: 1. The facility?s infection control policy provided during on-site inspection on 06/13/2022 included the following statement: ?11. Ensure the blood glucose meter is cleaned and disinfected after use according to manufacturer?s recommendations and stored appropriately (i.e., in a storage case, labeled with the patient?s name if dedicated for individual use).? 2. The glucometer for resident 10 was observed in the storage case for resident 11?s glucometer and the glucometer for resident 11 was observed in the storage case for resident 10?s glucometer during audit of medication cart B. This was also observed by staff 4.
Plan of Correction:	The facility ensured glucometers where correctly stored. Facility will continue to observe chart audit and educate RMAs on maintaining all facility?s medication management policy. Facility did inservices on recent violations and medication management policy.
Standard #:	22VAC40-73-150-C
Description:	Based on resident record review and observations of the facility physical plant, the administrator failed to be responsible for the general administration, management and oversight for the day-to-day operations of the facility to include implementing all policies, procedures and services as required. EVIDENCE: 1. The record for resident 6 contained documentation in progress notes of the resident smoking in the building on 03/13/2022, 03/14/2022, 03/19/2022, 04/27/2022, 06/09/2022 and 06/12/2022. 2. Observations made by 2 LI?s on the day of inspection of the room for resident 6 noted cigarette ashes on the window sill and cigarette ashes on the bathroom floor. The room was noted to smell of cigarette smoke. 3. The record for resident 6 has documentation of a? Rental Agreement Assisted Living/Memory Care? that was signed by resident 6 and the facility administrator on 03/10/2022. Documentation on page 12 of this agreement indicates ?The residents/responsible party acknowledges and agrees ?The Company? has a smoke and drug free environment policy (this includes but is not limited to e-cigarettes, vaporizers, pipes or other assistive smoking devices), which includes all interior areas. ?The Company? vehicles. Smoking shall only be permitted in designated exterior areas. The Resident/Responsible Party agrees to make arrangements to vacate the resident?s apartment upon notification if the smoke environment policy has been violated by Resident/Responsible Party, members of their family, guests, agents and or employees of the Resident/Responsible Party. If the smoke environment policy is violated by Resident/Responsible Party or Resident/Responsible Party?s family, guests, agents or employees, the Company may terminate this agreement and require Resident to vacate the Premises.? 4. A renewal study completed at the facility on 11/30/2021 and resulted in 31 violations in the areas of administration and administrative services, personnel, admission, retention and discharge of residents, resident care and related services, resident accommodations and related provisions, buildings and grounds, criminal background checks and sworn disclosure and a provisional license was issued effective 01/01/2022. Repeat violations have been cited in the areas of resident care and related services and building and grounds from complaint investigations, monitoring visits and a renewal study completed during this current licensure period.
Plan of Correction:	An unbiased analysis of the facility has been made which shows that there is need for repairs, renovation, upgrade of appliances and furniture, HVAC replacement, and sprinkler flushing which commensurate with the needs of a 35 years old building as opposed to attributing such needs to the failure of the administrator or personnel?s responsibility. Resident 6 smoking assessment has been done and her discharge process has been initiated per facility rental agreement. The 11/30/21 annual inspection has a record number of violations cited overturned in the history of Carriage Hill after first and second desk review due to those violations nor correctly cited. With the help of corporate office all the needs and projects required for upgrade of the physical plant has been approved. The facility is recovering from the impact of COVID-19 shutdown on staff shortage, staff burn out, and residents? well-being. The company has approved and scheduled capital expenditure. Additionally, a team of regional directors will be providing support for operation, clinical reviews, human resources, business office oversight. Regional human resource department has trained facility human resources on how to tidy staff record. A director of nursing, and a unit coordinator and compliance has been employed to provide support to the administrator. Weekend incentives has been introduced by the administrator which has boosted staff renumeration and morale for work. A psych practitioner has been hired by the administrator to support facility physician and to also provide services for facility psych population. Areas of repeat violations has been aggressively addressed and staff educated on severity and consequences that entails violating company policies. Educational consultant and other healthcare consultants have been employed by the facility for support.
Standard #:	22VAC40-73-325-B
Description:	Based on resident record review, the facility failed to ensure that an annual fall risk rating was completed for residents who are assessed as assisted living level of care. EVIDENCE: 1. The uniform assessment instrument (UAI) dated 08/28/2021 in the record for resident 2 has documentation that the resident is assessed at an assisted living level of care. The record for resident 2 has documentation that the last annual fall risk rating was completed on 05/02/2021. An interview was conducted with staff 3 and 8 in which staff 8 expressed that they did not have any other place where fall risk ratings are kept and that all fall risk ratings are placed in resident records. As of the end of the exit meeting conducted on the day of inspection, a current fall risk rating for resident 2 was not made available for the LI to review.
Plan of Correction:	Resident 2 fall ratings was done on January 6th 2022, and it?s now on file. Director of nursing will ensure chronological arrangement of documents. Facility will keep a separate record to track fall risk ratings to minimize reoccurrence.
Standard #:	22VAC40-73-430-H-1
Description:	Based on resident record review, the facility failed to ensure that a discharge statement was retained in resident records. EVIDENCE: 1. The record for resident 8, who has been discharged from the facility, did not contain documentation of a discharge statement. Interviews with staff 8 and 10 expressed that a discharge statement had not been completed at the time of resident 8?s discharge.
Plan of Correction:	Staff responsible for keeping discharge information and creating final statement was using a different form for discharge. Staff has been educated on the right form to use. A discharge notice will be sent to the discharged resident.
Standard #:	22VAC40-73-680-D
Description:	Based on observation during tour of the physical plant, resident interview and resident record review, 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 12 contained a uniform assessment instrument (UAI), dated 06/04/2022, which indicated the resident needs his medication administered/monitored by lay person (RMA/Nurse). The UAI also indicated that the resident is orientated to all spheres at all times. 2. 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 05/21/2021, pages 122-123 state the following: ?11. Stay with the client until he/she has swallowed the medications (check mouth PRN).? 3. At approximately 9:47AM during on-site inspection on 06/13/2022, one licensing inspector (LI) observed a plastic medication cup with applesauce and seven pills (one brown/dark colored pill, one red pill and five white pills) sitting on the bed in resident 12?s room. Interview with resident 12 revealed that the pills were his morning medications and that staff 3 had brought him the pills earlier on date of on-site inspection on 06/13/2022 and left them in his room. The medications were also observed by staff 8. The June 2022 medication administration record (MAR) for resident 12 indicates that staff 3 was the registered medication aide (RMA) that administered the medications to resident 12 on 06/13/2022 at 8:00AM.
Plan of Correction:	Facility notified resident physician who reviewed and made recommendations. Staff involved was counselled on the severity of her action and went through facility counselling and write up protocol. The director of nursing and administrator will continue to educate staff on compliance and conduct random room check after med pass.
Standard #:	22VAC40-73-680-M
Description:	Based on observation during medication cart audit, the facility failed to ensure that medications ordered for PRN (as needed) administration were available at the facility. EVIDENCE: The record for resident 9 contained a physician?s order, dated 05/12/2022, for Cepacol Extra Strength Lozenges. During medication cart audit, staff 4 revealed that the aforementioned medication was not available at the facility during on-site inspection on 06/13/2022.
Plan of Correction:	Facility pharmacy sent resident medication to the facility. Resident Care Coordinator will audit PRN orders and medications periodically to ensure Pharmacy?s failure to complete orders is identified at the right time. The DON and administrator will provide layers of supervision to ensure that PRN medication is refilled in a timely manner.
Standard #:	22VAC40-73-860-I
Description:	Based on observation during tour of the physical plant, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area. EVIDENCE: 1. At approximately 9:56 AM, one licensing inspector (LI) found the door unlocked to room 38 that contained three cleaning carts. The following chemicals were found in the room: 401K organic acid bowl cleaner, Great Value Linen Fresh Odor Eliminator, Conqueror Odor Counteractant cleaner, and two clear, plastic spray bottles with an unknown substance. 2. At 9:34AM one LI observed that the door to the housekeeping closet on the memory care unit was not locked. Various cleaning agents including Great Value Bleach, Multi-Surface and Glass Cleaner, Monogram Stainless Steel Cleaner, LaBamba Multipurpose Cleaner, Lysol Power Toilet Bowl Cleaner and Clorox Scentiva Disinfecting Cleaner were observed sitting out on shelfs in the housekeeping closet.
Plan of Correction:	The facility has relocated cleaning materials in the memory care unit and other units properly secured. All unit have been properly secured. Housekeeping and maintenance directors will routinely monitor chats, materials, and staff diligence on all shifts.
Standard #:	22VAC40-73-870-A
Description:	Based on observations of the facility physical plant, the facility failed to maintain the interior of the building in good repair and kept clean and free of rubbish. EVIDENCE: 1. At approximately 10:06AM during on-site inspection on 06/13/2022, one licensing inspector (LI) observed room 21 with multiple Equal packets, multiple empty Oreo packages beside the resident?s bed, plastic cups containing water on the floor, the trash can overflowing with incontinence supplies and the sheets on the resident?s bed contained multiple small spots of a brown substance. At approximately 11:29AM when the LI went back into room 21, the resident?s sheet were still dirty and the LI observed the plastic mattress cover has having a multiple brown substances as the flat sheet on the bed had been pulled back. 2. Stains were noted on the carpet in room 12 on the memory care unit. 3. The plastic strip on the floor between the dining room and sitting room in the memory care unit was noted to be loose and coming up from the floor on both ends of the strip. 4. The light switch plate in the bathroom of room 15 on the memory care unit was noted to be missing all screws and the electrical wiring was visible behind the switch plate. Also, the light switch plate in the bathroom of resident 6?s room was noted to be missing. 5. A large area of water, food and other debris was observed on the floor around the drain in the kitchen on the memory care unit. Interviews with staff expressed that when the dishwasher is used water and food flow up from the drain. 6. The LI observed at 9:25am multiple areas of food, liquid spills, and other dried substances on the dining room floor and dining tables. Interviews with staff expressed that breakfast was served at 8:00am and that at the time of observation, the dining room had not been cleaned. 7. The ceiling in the hallway by the exit doors on the right side of the Mountainside dining room was noted to have an area of peeling paint/tape.
Plan of Correction:	Facility wide renovation and refurbishment of old structure, parts, and HVAC system is on-going. Housekeeping and maintenance department were educated on the severity of compliance. A systemic twice-daily routine rounds by housekeeping staff was put in place to monitor and keep troubled rooms or rooms suspected to have hoarding features for regular upkeeping. An expedited plan was coordinated with regional director of operations and maintenance director to facilitate the completion of painting, repairs, and HVAC system replacement.
Standard #:	22VAC40-73-870-B
Description:	Based on observation during a tour of the physical plant, the facility failed to ensure the building was free from foul and stale odors. EVIDENCE: 1. At approximately 10:11AM during on-site inspection on 06/13/2022, one licensing inspector (LI) entered resident 13?s room and there was a strong odor of urine present in the resident?s bathroom. This was also noted by staff 8. 2. A foul odor was noted coming from the kitchen and into the dining room area in the memory care unit at 9:10am on the day of inspection.
Plan of Correction:	Renovation of troubled rooms and old rooms are on-going. While this reconstruction and renovation are on-going, residents are being relocated. Resident 13 was relocated to a new room immediately. Toilet and bathroom flooring will be replaced, and room painted before the room is available. Facility has a room availability template to monitor rooms that are due for renovation.
Standard #:	22VAC40-73-870-E
Description:	Based on observations made of the facility physical plant, the facility failed to keep all furnishings, fixtures and equipment clean and in good repair. EVIDENCE: 1. A dried brown substance was noted on the toilet in room 12 on the memory care unit. 2. The mattress and box springs on the bed in room 22 of the memory care unit were noted to be soiled.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-880-C
Description:	Based on observation during tour of the physical plant, the facility failed to ensure that temperatures in all areas used by resident did not exceed 80 degrees Fahrenheit. EVIDENCE: At approximately 4:08PM through 4:13PM during on-site inspection on 06/13/2022, it was noted by one licensing inspector (LI) and staff 7 and 8 the following in the facility?s assisted living building: in the lobby of the facility a clock that was located on the wall behind the receptionist?s desk displayed the temperature as 81.5 degrees Fahrenheit, the thermostat located outside the kitchen door in the dining room displayed the temperature as 82 degrees Fahrenheit and the thermostat located on C hall of the facility displayed the temperature as 81 degrees Fahrenheit.
Plan of Correction:	Facility procured two units of HVAC to common areas. Maintenance department has a service plan to monitor common areas and rooms which ensures areas used by residents does not exceed 80F. Witt Mechanical has been working with the facility and quotation was made available to license inspector during inspection and completion of work that was delayed due to parts late delivery has been completed once parts was delivered. Witt Mechanical confirmed parts delivered, and work completion date confirmed. Temperature log for common areas has been put in place to monitor and ensure compliance.