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 24, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 06/24/2022 through 06/30/2022 8:20AM through 12:30PM. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/23/2022 regarding allegations in the areas of: staffing/personnel and resident care and related services. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-200-C
Complaint related:	Yes
Description:	Based on staff record review and staff interview, the facility failed to ensure that staff that provide direct care met one of the requirements. EVIDENCE: During on-site inspection on 06/24/2022, a phone interview was conducted with staff 3 in the presence of staff 1 and 2. Staff 3 revealed that on 06/23/2022 during her shift staff 4 assisted her in transferring resident 1 off the toilet back into his motorized chair and that the resident is a two person assist. Interview with staff 1 and 2 confirmed that staff 4 does not have the required direct care training and staff 1 confirmed that the resident is a two person assist.
Plan of Correction:	Facility has employed staffing agency to support direct care staff. System and provisions have been put in place to train non-direct care staff in direct care training.
Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on document review, resident record review, and staff interview the facility failed to implement their medication management plan. EVIDENCE: 1. The facility?s medication management plan provided to the licensing inspectors on the day of inspection indicated the following: ?4. Methods to ensure that each resident?s prescription medications and any over the counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Daily procedures for refill request: refills need to be faxed to pharmacy daily. If refill is needed immediately, please call and fax the pharmacy with order so delivery can be made as soon as possible. All controlled medications, PRN medications or treatments should be re-ordered when there is a five (5) day supply left.? The May and June 2022 medication administration record (MAR) for resident 1 has a physician order for Morphine Sulf ER Tab 30mg, take one tablet by mouth three times a day for pain. Staff initials are circled as not administering this medication at 10pm on 05/23/2022 and at 6am on 05/24/2022 with documentation that it was not administered due to ?doctor order?. Staff initials are circled as not administering this medication at 6am on 06/24/2022 with documentation that the medication was not administered due to ?other ord?. In an interview with staff 1 in the presence of staff 2 this documentation indicates that the medication was unavailable and that they were waiting for the medication to be delivered from the pharmacy. 2. The facility?s medication management plan also indicated the following: ?No less than daily, 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. DON and/or charge nurse will monitor daily.? During on-site inspection on 06/24/2022, staff 1 was the staff person who had possession of the keys to medication carts A, B, C, and D and had taken possession of the keys to all the medication carts from staff 5 at the end of staff 5?s shift. Interview with staff 1 revealed that she did not count the controlled narcotics with staff 5 and also did not sign the ?Shift to Shift Narcotic Count Sign Off Sheet? for the medication carts. This was also noted by staff 2. The ?Shift to Shift Narcotic Count Sign Off Sheet? for Cart A did not contain the signature of the staff for ?7A-7P? off shift on 06/23/2022. The ?Shift to Shift Narcotic Count Sign Off Sheet? for Cart B did not contain the signature of the staff for ?7A-7P? off shift on 06/22/2022. The ?Shift to Shift Narcotic Count Sign Off Sheet? for Cart C did not contain the signature of the staff for ?7P-7A? on shift and ?7P-7A? off shift for the dates of 06/20/2022 and 06/22-23/2022.
Plan of Correction:	DON will ensure RMAs are trained on proper documentation to identify when resident is out of the facility either for an extended pain management visit or being sent to the ER due to a fall or emergency. DON will monitor NARC sheet and EMAR to ensure dates when resident is out of the facility properly documented. DON or designee will conduct random audits throughout the week.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on resident record review and staff interview, the facility failed to ensure that all medications were administered in accordance with physician?s instructions. EVIDENCE: The record for resident 1 has a physician order dated 05/09/2022 to ?Please have Med Tech/LPN witnessed when administering controlled substances. Both Med Tech and witness need to sign?. On the day of inspection, it was noted that there is no documentation of a witness signing when a controlled substance was administered to resident 1. In an interview with staff 1 conducted in the presence of staff 2 it was expressed that the administration of controlled substances to resident 1 is not always being witnessed as per the physician order dated 05/09/2022.
Plan of Correction:	A tool for documenting two witness signatures was created and it's in use.
Standard #:	22VAC40-73-680-E
Complaint related:	No
Description:	Based on observation, resident record review and staff interview, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber were provided according to his instructions and documented. EVIDENCE: The record for resident 1 contained a physician?s order, dated 06/23/2022, for the following: ?Tubi grips RLE. Apply in AM and remove @ suppertime.? On day of inspection, one licensing inspector observed the resident not wearing Tubigrips throughout the morning. This was also observed by staff 6 at approximately 11:30AM.
Plan of Correction:	Physician order was written in less than 24 hours before inspection. Facility will continue to anticipate need when pharmacy is unable to make delivery. Facility will invest on emergency supplies.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on resident record review, facility documentation, and staff interviews, the facility failed to ensure that all required information was documented on resident medication administration records (MARs). EVIDENCE: 1. The narcotic count log for resident 1?s prescribed Morphine Sulf ER 30mg tablets was reviewed on the day of inspection and a discrepancy was noted with the count of the medication. In a phone interview conducted in the presence of staff 1 and 2 with staff 3 ,it was explained that on 06/23/2022 at 2pm staff 3 signed resident 1?s June 2022 MAR for the administration of his prescribed Morphine Sulf ER 30mg. The medication was not administered because resident 1 was out of the building. Staff 3 expressed that they were unable to circle or document the medication as not administered on resident 1?s June 2022 MAR as required because the facility E-MAR (electronic medication administration record) system will not allow changes in the E-MAR system once a medication has been documented as administered.
Plan of Correction:	Staff on duty could not reverse documentation on EMAR. Inability to reverse EMAR activities is for accountability. Staff has been educated on the importance of notifying supervisor and properly documenting in nurses progress notes if such an incident reoccurs.