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 26, 2022 and Aug. 2, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 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: 07/26/2022 2:10AM through 3:00AM & 08/02/2022 9:40AM through 10:45AM 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 07/19/2022 regarding allegations in the areas of: staffing and supervision, resident care and related services, and additional requirements for facilities that care for adults with serious cognitive impairments. 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 #:	22VAC40-73-1020-A
Complaint related:	Yes
Description:	Based on document review and staff interview, the facility, which consists of a mixed population of residents, 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 shall be responsible for the care and supervision of the residents. EVIDENCE: 1. At 2:15AM on 07/26/2022, one licensing inspector (LI) observed staff 2 outside of the Morningside (assisted living) building along with staff 1. Staff 2 was scheduled to be on duty in the assisted living building. Interviews conducted by two LI?s with multiple staff on 07/26/2022 expressed that staff 2 has frequently left the assisted living building during their scheduled 7:00PM to 7:00AM shifts, leaving only one direct care staff member present to provide care to residents residing in the assisted living building. 2. During on-site visit on 07/26/2022, staff 10, who was on-duty in the assisted living building from 7:00PM to 7:00AM, revealed to two LIs that she was going across the road to the Peaksview (special care unit) building to administer resident 2?s scheduled morphine every two hours because she was the only registered medication aide (RMA) on duty therefore leaving only one direct care staff in the building if staff 2 was present and on-duty in the assisted living building at the time. 3. Interview with staff 3 and 4 on 08/02/2022 revealed and confirmed that residents 3, 4 and 5 would not be able either physically and/or mentally to protect themselves from danger and/or be able to exit the facility on their own, either physically and/or mentally, in case of an emergency such as a fire. Therefore, the facility serves a mixed population of residents. 4. The uniform assessment instrument (UAI) for resident 3, dated 05/11/2022, indicates that the resident is disoriented ? some spheres, all the time to the following spheres: time, place and situation. The ?Report of Resident Physical Examination? for resident 3, dated 06/04/2017, lists ?Alzheimer?s Dementia? for ?significant medical history? and ?diagnosis or significant problems?. 5. The UAI for resident 4, dated 10/28/2021, indicates that the resident is disoriented ? some spheres, some of the time to place. 6. The UAI for resident 5, dated 09/13/2021, indicates that the resident has a history of dementia. The ?Report of Resident Physical Examination? for resident 5, dated 09/30/2016, lists ?Dementia? for ?significant medical history?. The individualized service plans (ISPs) for resident 3, dated 05/11/2022; resident 4, with a review date of 07/21/2022; and resident 5, with a review date of 06/05/2022, indicates that the orientation for residents 3, 4 and 5 is ?Confusion/forgetfulness (short term/long term memory impairments) Resident will be redirected & reoriented with verbal, physical, &/or written reminders as needed & structure & supervision will be provided. Staff will re-direct and orient resident during periods of confusion.? 7. Interview with staff 3 on 07/26/2022 revealed that she (staff 3) was the only direct care staff member in the assisted living on duty from 7:00AM until 7:00PM on 07/23/2022.
Plan of Correction:	Written disciplinary action completed for staff# 1 and 2; counseling session included the review of the responsibilities of direct care staff. Break times and location of designated break areas reviewed. Master schedule reviewed with staffing coordinator and administrator no less than weekly. Company approval for overtime and utilization of external agencies has been granted while recruitment efforts continue. Three current CNAs enrolled in RMA class in September. Five managers currently enrolled in DCA training that is scheduled to be completed no later than 9/30/2022. Utilization of managers for direct care will be an emergency contingency plan to maintain minimum staffing requirements. All staffing emergencies are to be reported to administrator and regional designees in real time. Staffing patterns reviewed no less than 5 times a week during morning stand up meeting. A minimum of one regional designee will participate in daily meetings.
Standard #:	22VAC40-73-1130-A
Complaint related:	Yes
Description:	Based on staff interviews and a review of facility daily assignment sheets and employee time sheets, the facility failed to ensure that at least two direct care staff members were awake and on duty at all times in the special care unit when 20 or fewer residents are present. EVIDENCE: 1. In an interview conducted by two LI?s on 07/26/2022 with staff 3, it was expressed that staff 9 was the only direct care staff member on duty in the special care unit from 12:00pm until 3:00pm on 07/23/2022. 2. On the day of inspection the licensing inspectors (LI?s) requested staff time sheets that included 07/23/2022. Documentation on the time sheets shows that staff 9 clocked in at 11:45am on 07/23/2022. Staff 2 clocked out at 12:15pm and staff 1 clocked out at 12:30pm on 07/23/2022. Staff 9 was the only direct care staff member on duty on the special care unit from 12:30pm until 4:00pm.
Plan of Correction:	Written disciplinary action for staff 1 and 2 completed as indicated. Facility meal program initiated free of charge for overnight personnel. Review of designated break and smoking areas that are within their assigned work areas. These policies will be reviewed by the HR Director for all new hires during orientation. Regional designees (staff 12 and 13) met with staff #4 to review responsibilities of the administrator of record. New executive director commences employment by October 1, 2022 and will monitor plan of correction to ensure ongoing compliance. Master schedule reviewed with staffing coordinator and administrator no less than weekly. Company approval for overtime and utilization of external agencies has been granted while recruitment efforts continue. Three current CNAs enrolled in RMA class in September. Five managers currently enrolled in DCA training that is scheduled to be completed no later than 9/30/2022. Utilization of managers for direct care will be an emergency contingency plan to maintain minimum staffing requirements. All staffing emergencies are to be reported to administrator and regional designees in real time. Staffing patterns reviewed no less than 5 times a week during morning stand up meeting. A minimum of one regional designee will participate in daily meetings. Administrator of record conducted meetings with management team, medication techs and care givers to review violation notices dated 7/26 and 8/2/2022.
Standard #:	22VAC40-73-1130-C
Complaint related:	Yes
Description:	Based on observations made during an on-site visit and staff interviews, the facility failed to ensure that at least 2 direct care staff members were awake and on duty at all times in the special care unit when 22 or fewer residents are present. EVIDENCE: 1. At 2:15am on 07/26/2022, one licensing inspector (LI) entered the facility?s special care unit and observed that only one direct care staff member was present on the special care unit with 16 residents currently in care. Another LI observed that staff 1, who was scheduled to be on duty in the special care unit, was sitting in a car smoking across the street at the Morningside (assisted living) building. 2. Interviews conducted by two LI?s with multiple staff on 07/26/2022 expressed that staff 1 has frequently left the special care unit during their scheduled 7pm to 7am shifts, leaving only one direct care staff member present to provide care to residents residing in the special care unit. 3. In an interview conducted by two LI?s on 07/26/2022 with staff 3 it was expressed that they had been made aware sometime in the past several weeks of staff 1 leaving the special care unit during their shift. Staff 1 voiced that they had talked to staff 1 about not leaving the special care unit when only 2 direct care staff members are present but could not remember exactly when this conversation took place. Staff 1 also expressed that they had made the facility administrator aware. 4. In an interview conducted by two LI?s on 07/26/2022 with staff 4, and in the presence of staff 5, it was expressed by staff 4 that they were aware of staff person 1 leaving the special care unit during their scheduled shifts, leaving only one direct care staff member on duty on the unit, but as of the date of this inspection they had not addressed it.
Plan of Correction:	Regional designees (staff 12 and 13) met with staff3 and 4 regarding minimum staffing requirements. Staff 3 and 4 understand the significance of their responsibilities with staffing coverage and escalating challenges to regional designees in real time. Master schedule reviewed no less than weekly in morning stand up meetings with the regional office. DCA and RMA classes are scheduled and in progress. Recruitment efforts continue with favorable results. Staff referral incentives initiated, salary adjustments for hourly employees completed to bring our wages above the fair market value. Company continues to approve overtime and external agency use. Monitoring systems and staff responsibility same as outlined above in 1130-C.
Standard #:	22VAC40-73-150-C
Complaint related:	Yes
Description:	Based on observations made during an on-site visit and staff interviews, 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. At 2:15am on 07/26/2022, one licensing inspector (LI) observed staff 1 and 2 outside of the Morningside (assisted living) building. Staff 1 was supposed to be on duty in the facility?s Peaksview (special care unit) building and staff 2 was supposed to be on duty in the facility?s assisted living building. 2. Interviews conducted by two LI?s with multiple staff on 07/26/2022 expressed that staff 1 frequently leaves the assisted living building and staff 2 frequently leaves the special care unit during their scheduled 7:00PM to 7:00AM shifts, leaving only one direct care staff member present to provide care to residents residing in the assisted living building and the special care unit building. 3. In an interview with staff 4 on 07/26/2022 it was expressed that she was aware of the situation but was not aware of disciplinary actions that she could conduct with staff 1 and 2. When staff 4 was questioned if she had informed corporate of the situation she stated that she had not.
Plan of Correction:	Written disciplinary action completed for staff 1 and 2; counseling session included the responsibilities of direct care staff. Facility meal program initiated free of charge for overnight personnel. Review of designated break and smoking areas that are within their assigned work areas. These policies will be reviewed by the HR Director for all new hires during orientation. Regional designees (staff 12 and 13) met with staff #4 to review responsibilities of the administrator of record. New executive director commences employment by October 1, 2022 and will monitor plan of correction to ensure ongoing compliance. Administrator of record will submit written report to regional office no less than monthly confirming status of compliance. Any subsequent employee violations of this nature will be escalated to regional designees in real time for guidance with disciplinary action.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on a review of resident medication administration records (MARs), narcotic count logs and staff interviews, the facility failed to ensure that all required information was documented on resident MARs. EVIDENCE: The June 2022 MAR for resident 1 contained documentation that staff 3 had administered the resident Hydrocodone at 8:00PM on 06/11/2022 and 06/12/2022. Interview with staff 3 revealed that she did not administer the medication because it was not available in the facility and that she was unable to circle or document the medication as not administered on resident 1?s MAR as required because the facility E-MAR system will not allow changes in the E-MAR system once a medication has been documented as administered.
Plan of Correction:	Counseling session with staff#3 conducted to review medication management standards as it relates to medication availability. Staff #3 did facilitate hard script for resident #l's controlled substance. Staff #3 in-serviced on the fact that a narrative entry in the resident's medical record is acceptable for supporting documentation. DON conducted in-service with all medication techs to review violation notice. Training provided to all med techs on standard of practice with narrative entry in medical records as it pertains to challenges with medication availability. Notation in medical record to include physician and responsible party notification as applicable. DON and/or designee will monitor pharmacy dashboard no less than weekly for oversight of any missed medication doses. Regional nurse will monitor for ongoing substantial compliance during on site and/or monthly remote visits. Nurse Consultant with preferred pharmacy provider will monitor no less than quarterly with health care oversight visits.