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: July 15, 2022

Complaint Related: Yes

Areas Reviewed:

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

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: July 15, 2022 12:00PM until 2:00PM and July 19, 2022 10:30AM until 12:00PM 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 07/11/2022 regarding allegations in the area of resident care and related services. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were resident care and related services. A violation notice was 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 #:	22VAC40-73-440-D
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that the uniform assessment instrument (UAI) was completed as required. EVIDENCE: The UAI for resident 2, dated 10/13/2021, indicated that the resident does not require assistance with bathing; however, interview with staff 5 on 07/15/2022 revealed that the resident does require human assistance with bathing in the form of ?cueing? to ensure that the resident has showered. This was also noted by Collateral 1 and staff 1.
Plan of Correction:	UAI?S and ISPs for residents #1, #2 & #3 were reviewed and updated according to resident need.
Standard #:	22VAC40-73-460-H
Complaint related:	No
Description:	Based upon resident record review and staff interview, the facility failed to ensure that personal assistance and care were provided to each resident as necessary so that the needs of the resident are met including assistance with bathing at least twice a week. EVIDENCE: 1. The uniform assessment instrument (UAI), dated 03/25/2022, and the individualized service plan (ISP), dated 03/25/2022, for resident 1 indicate that the resident needs mechanical and human physical help and that ?staff will provide (resident 1) complete assistance with bathing and getting in/out of shower safely?. The licensing inspector (LI) requested documentation of resident?s showers and was provided ?Skin Monitoring: Comprehensive CNA Shower Review? sheets on 07/15/2022 and additional information provided to the LI by staff 4 on 07/19/2022 which indicated the following: during the week of 06/05/2022 through 06/11/2022 there was no documentation that the resident received any showers, during the time period of 06/19/2022 through 07/02/2022 there was no documentation that the resident received any showers and during the time period of 07/03/2022 through 07/19/2022 there was documentation that indicated the resident received only one shower. 2. The UAI for resident 2, dated 10/13/2021, indicated that the resident does not require assistance with bathing; however, interview with staff 5 on 07/15/2022 revealed that the resident does require human assistance with bathing in the form of ?cueing? to ensure that the resident has showered. The licensing inspector (LI) requested documentation of resident?s showers and was provided ?Skin Monitoring: Comprehensive CNA Shower Review? sheets on 07/15/2022 which indicated the following: during the week of 06/12/2022 through 06/18/2022 there was no documentation to show that the resident had received any showers and during the time period 06/19/2022 through 07/02/2022 there was documentation that the resident only received two showers. 3. The UAI for resident 3, dated 04/18/2022, indicated that the resident requires human physical help with bathing, and the ISP for the resident, dated 04/18/2022, indicated that ?staff will provide complete assistance with bathing and getting in/out of shower safely while encouraging resident to participate as able.? The licensing inspector (LI) requested documentation of resident?s showers and was provided ?Skin Monitoring: Comprehensive CNA Shower Review? sheets on 07/15/2022 which indicated the following: During the week of 06/19/2022 through 06/25/2022 there was documentation that the resident only received one shower and during the time period 07/03/2022 until 07/15/2022 the resident had only received one shower. During additional on-site visit on 07/19/2022, staff 4 did not provide additional documentation to the LI regarding showers/bathing for residents 2 and 3.
Plan of Correction:	Skin monitoring/ shower review forms will be submitted to the DON or med tech designee at the end of scheduled shift. DON or med tech will make an entry in 24-hour report confirming shower has been completed. Any refusal will be documented in the 24-hour report notation. DON met with nursing staff to review new process.
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure that medications were administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1 contained the following physician?s order dated 05/12/2022: ?start Novolog 10 units TID (three times daily) w/ meals. Hold Novolog if eats less than 50% of meals and hold Novolog if mealtime BS (blood sugar) less than 150?. The June 2022 medication administration record (MAR) for resident 1 indicated that on 06/23/2022 the resident?s blood sugar at 5:00PM was 124 and on 06/29/2022 the resident?s blood sugar at 5:00PM was 125; however, the June 2022 MAR indicated that the resident was administered Novolog by staff 3 on 06/23/2022 at 5:00PM and by staff 2 on 06/29/2022 at 5:00PM. Also, the June MAR indicated the resident?s blood sugar at 8:00AM on 06/07/2022 was 187 and there was no documentation to show the percentage the resident ate of his meal and staff 2 did not administer Novolog to the resident on 06/07/2022 at 9:00AM. The July 2022 MAR for resident 1 indicated that on 07/09/2022 the resident?s blood sugar at 12:00PM was 125 and on 07/14/2022 the resident?s blood sugar at 12:00PM was 125; however the resident was administered Novolog on both of these dates/times by staff 2. The July 2022 MAR for the resident indicated that on 07/01/2022 the resident?s blood sugar at 5:00PM was 380 and that the resident had eaten 100% of his meal; however, staff 4 did not administer the resident?s Novolog due to ?Other: blood sugar <150? on 07/01/2022. 2. The record for resident 1 contained the following physician?s order dated 05/12/2022: ?start Lantus 66 unit every AM (morning). Hold Lantus if fasting (pre breakfast) BS (blood sugar) is < (less than) 150.? The June 2022 MAR for the resident indicated that on 06/13/2022 at 8:00AM the resident?s blood sugar was 125; however staff 2 administered the resident Lantus at 8:00AM on 06/13/2022. Also, on 06/03/2022 at 8:00AM the resident?s blood sugar was 170; however staff 4 did not administer the resident Lantus due to ?other: bs <150? on 06/03/2022. The July 2022 MAR for the resident indicated that on 07/11/2022 at 8:00AM the resident?s blood sugar was 101; however staff 2 administered the resident Lantus at 8:00AM on 07/11/2022. Also, the on 07/14/2022 at 8:00AM the resident?s blood sugar was 127; however staff 2 administered the resident Lantus at 8:00AM on 07/14/2022.
Plan of Correction:	DON/Acting administrator and HR director met with staff #3 to review findings of 07/15/2022 violation notice. Written counseling completed and on file. Dr. Bell notified of errors with insulin administration and documentation of meal consumption.
Standard #:	22VAC40-73-780-B
Complaint related:	No
Description:	Based on observation of a resident?s room, the facility failed to ensure that bed linens were changed as needed. EVIDENCE: 1. At approximately 12:27PM on date of inspection, the licensing inspector along with Collateral 1 and staff 1, 6 and 7 noted that the fitted sheet on resident 3?s bed contained multiple stains and the resident?s pillow did not have a pillow case. 2. Also, at approximately 12:57PM a balled up washcloth was observed by the LI, Collateral 1 and staff 1, 6 and 7 in resident 2?s shower that contained a brown substance.
Plan of Correction:	Residents bed for #2 and #3 were disinfected. Soiled linens were discarded. Laundry standards were reviewed with housekeeping supervisor and memory care staff. Carriage Hill Retirement will enter into an agreement with a third-party provider for linen services for sheets, pillowcases, towels, and washcloths before August 31, 2022.
Standard #:	22VAC40-73-870-B
Complaint related:	No
Description:	Based on observation of a resident?s room, the facility failed to ensure that all buildings were free from foul and stale odors. EVIDENCE: On date of on-site inspection at approximately 12:20PM, the licensing inspector (LI) along with Collateral 1 and staff 1 noted a strong smell of urine upon entering resident 3?s room.
Plan of Correction:	Resident #3 room was disinfected; soiled linens removed, and laundry done. Odor subsided on completion. Housekeeping and laundry standards reviewed with housekeeping supervisor and memory care staff.
Standard #:	22VAC40-73-870-E
Complaint related:	No
Description:	Based on observation of residents? rooms, the facility failed to ensure that all furnishings, including furniture and toilets, were kept clean. EVIDENCE: 1. On date of on-site inspection at approximately 12:25PM, the licensing inspector (LI) along with Collateral 1 and staff 1 noted that the chair in resident?s 3 room contained a white sheet that had been folded up on top of the cushion. Upon removing the sheet from the chair?s cushion, it was noted that the cushion of the chair contained dried feces. This was observed by staff 1, 6 and 7 and Collateral 1. 2. At approximately 12:57PM, the LI along with Collateral 1 and staff 1, 6 and 7 noted that the toilet in resident 2?s room contained a brown substance on the outside of the toilet.
Plan of Correction:	Staff #7 terminated 07/15/2022. Resident rooms for #2 and #3 were deep cleaned and properly disinfected. Routine wellness checks for memory care residents will include spot checking of the resident?s room and furnishings. Housekeeping standards reviewed with housekeeping supervisor and memory care staff.