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: Dec. 8, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 12/08/2022 9:00AM until 3:15PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. mandated monitoring inspection was conducted by the inspector of record for the facility in conjunction with two other licensing inspectors with the VDSS DOLP. The inspection was conducted as a probation inspection that was indicated in the special order that was issued to the facility on 06/17/2022 and a denial inspection that was indicated in the notice of intent (NOI) that was issued to the facility on 09/10/2022. 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 #:	22VAC40-73-50-A
Description:	Based on resident record review, the facility failed to ensure that the disclosure statement provided to resident contained all required information. EVIDENCE: 1. The disclosures statements in the records for residents 2, 3 and 4 did not contain any information for the number of staff providing direct care per shift on the 11-7 shift.
Plan of Correction:	? 1.The residents Disclosure statements for residents 2, 3 and 4 was corrected and updated on 12/09/2022 with a new copy mailed for families to be aware of needed changes ? 2. Marketing/ Administrator or Designee to audit all charts to ensure all disclosure statements reflect corrections. Completion Date-01/15/2023 ? 3. Disclosure Statement revised to reflect needed changes on 12/09/2022 and updates made aware to Marketing Manager and Wellness Director. ? 6.Completion Date- 12/09/2022
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure that identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The ISP for resident 2, dated 11/26/2022, did not indicate that the resident requires compression stockings. 2. The record for resident 3 contained a history and physical, dated 11/28/2022, that the resident is on a No Added Salt diet. The ISP dated 12/01/2022 in the record for resident 3 does not address this identified need.
Plan of Correction:	? 1.ISP for resident 2 and 3 updated on 12/09/2022 to reflect needed corrections. ? 2.Wellness Nurse/DON/Administrator or Designee to review all ISP/UAIs for accuracy by 01/15/2023 ? 3. Wellness Nurse/DON or designee to audit 5 files a month for accuracy on ISP/UAIs beginning 12/31/2022. ? 4.Completion Date 01/15/2023
Standard #:	22VAC40-73-660-B
Description:	Based on observation and resident record review, the facility failed to ensure that for a resident with medications in their room the uniform assessment instrument (UAI) indicated the resident is capable of self-administering medication. EVIDENCE: At approximately 9:54AM during on-site inspection, one licensing inspector (LI) observed a bottle of Excedrin extra strength pain reliever, a spray bottle of Fluticasone Propionate nasal spray, an orange prescription bottle without a label that contained two unidentified pills (one oblong white and one oblong red), and a bottle of Advil pain reliever. The private pay UAI for resident 2, dated 09/14/2022, indicated that the resident requires their medication to be administered/monitored by a lay person. Interview with staff 1 and 2 confirmed resident did not contain a physician?s order for the resident to be able to have these medications in her room and self-administer.
Plan of Correction:	? 1.All mangers on duty completed an entire room/building sweep for compliance on 12/08/2022 after inspection. ? 2. A deep clean/Room sweep checklist and daily room assignments of at least 2 rooms per day will be initiated for housekeeping and nursing staff. A checklist and sheet for Wellness Nurse/Administrator or designee to review for assigned rooms will be implemented. Completion Date- 01/15/2023 ? 3. A memo will be sent out to all family/residents and staff regarding compliance of the regulations and allowed items in residents rooms and staff areas. Completion Date 12/31/2022 ? 4.Completion Date -01/15/2023
Standard #:	22VAC40-73-680-E
Description:	Based on observation, resident record review, and staff interview, the facility failed to ensure treatments ordered by a physician or other prescriber were provided according to his instructions and documented. EVIDENCE: 1. The record for resident 2, admitted 11/27/2022, contained a history and physical examination report dated 11/06/2022, which included signed physician?s orders for compression stockings to be applied in the morning and removed at bedtime. In addition, new admit physician?s orders signed on 11/29/2022 indicated no new orders ?NNO?. The December 2022 medication administration record (MAR) for resident 2 did not contain documentation of compression stockings nor that they have been applied and removed as per physician?s orders. 2. Interview with staff 3 revealed that the compression stockings would not be found on a separate record such as a treatment administration record. Staff 3 added that she was unaware that resident 2 required compression stockings. 3. At approximately 11:00AM, one licensing inspector (LI) observed that resident 2 was not wearing compression stockings.
Plan of Correction:	? 1. MD notified on 12/08/2022 and order reviewed and clarified. ? 2. Wellness Director/DON and Designee will audit 5 files monthly for compliance on UAI/ISPs. ? Completion Date ? 01/01/2023 ? 3. DON/Wellness Director and Designee to Audit all new Residents H&PS AND EMAR (orders) on Admission as well as within 5 days of Admission. ? 4.Completion Date- 12/31/2022
Standard #:	22VAC40-73-820-A
Description:	Based on observation, resident record review and staff interview, the facility failed to ensure smoking by a resident is only done in areas designated by the facility and approved by the State Fire Marshall of local fire official. EVIDENCE: The record for resident 5 contained a safe smoking evaluation signed by the resident on 06/17/2022 that the resident is not a safe smoker due to smoking in his room. The record also contained a safe smoking evaluation signed by the resident on 08/09/2022 that he continues to not be a safe smoker due to being caught smoking in his room and that lighters and cigarettes will be secured with nursing staff and that the resident will be discharged if he is caught smoking again in his room. At approximately 9:48AM during on-site inspection, one licensing inspector (LI) noted upon entering resident 5?s room that the room smelled like cigarette smoke. The LI observed a cigarette butt with ashes in the toilet and a lighter on the resident?s bathroom sink along with an empty cigarette box.
Plan of Correction:	? 1.Resident 5 is currently on a discharge notice since 09/2022 awaiting placement. The caseworker and Administrator continue contact regarding placement to a new facility. ? 2.Inservice to resident and staff regarding safe smoking procedures to ensure the safety of Resident #5. ? 3. Administrator/ Wellness Nurse or Designee will implement every 1-hour checks to ensure safe smoking procedures and being followed along with room checks for smoking by nursing staff or designee every hour until discharge occurs. 4.Completion Date- 12/31/2022
Standard #:	22VAC40-73-860-I
Description:	Based on observation during a tour of the assisted living and safe, secure unit, the facility failed to ensure cleaning supplies and other hazardous materials were stored in a locked area. EVIDENCE: 1. At approximately 10:00AM during on-site inspection, one licensing inspector (LI) noted a container of Clorox disinfecting wipes located by the bathroom in resident 6?s room which is located in the assisted living building. 2. At approximately 10:02AM, two LIs noted that the door to the therapy room in the assisted living building was opened and no staff were present in or around the room. The LIs noted a container of Super sani-cloth germicidal disposable wipes, a container of Perk disinfecting wipes and multiple bottles of Purell hand sanitizer. All of the aforementioned items contained information to keep out of the reach of children. 3. At approximately 9:05 AM, one LI entered the double doors to the right side of the kitchen in the facility?s safe, secure unit and at the far end of the left side of the hallway, the LI observed a door with keys hanging from the knob and a sign stating ?SPRINKLER CONTROL IS BEHIND THIS DOOR?. The LI was able to enter the area and found overhead cabinets that contained the following cleaning products: Mop & Glo floor cleaner, Glade Pet carpet powder, SparCreme liquid creme cleanser, Conqueror 103 odor counteractant concentrate, HI TECH 401K organic acid bowl cleaner, Energy Mizer multi-surface and glass cleaner, McKesson hand sanitizer, Super Sorb spot absorbent, United Aqua Sponge gel and spill absorbent, Clean Shower daily shower cleanser, and Monogram stainless steel cleaner and polish. The lower cabinet contained bags of McKesson premium hand sanitizer with aloe. The room also contained an unlocked door with a sign that said ?MECHANICAL ROOM? which contained what appeared to be water heater tanks, pipes, hoses, knobs, and breaker boxes. 4. At approximately 9:13 AM, the bathroom in room 21 in the safe, secure unit had a bottle of Equate smoothing keratin shampoo sitting on the sink. 5. At approximately 9:58 AM, at the nurses? station, one LI observed a green and orange cylinder that said strawberry watermelon and had a pointed tip sitting next to the telephone in which the LI observed a resident standing at the nurses? and the object was within reach of the resident. Interview with staff 3 indicated that the aforementioned object was a vaping device.
Plan of Correction:	? 1. All managers on duty conducted an entire sweep of building/rooms on 12/08/2022 after inspection. ? 2. Keypad locks for both storage area doors ordered with an expected delivery date of 12-21-2022. Installation of keypads for 2 storage areas doors to be completed upon delivery. ? 3. A letter/memo was created for all Residents/Family as well as staff to be sent out via mail and email to provide education and a review of policy?s regarding allowed items and to ensure knowledge of regulations by all Residents/Families and staff: Completion Date: 12/31/2022 ? 4.Nurses Station areas to have twice weekly checks for compliance and education given by wellness director / housekeeping and designee. ? 5. Completion Date- 12/31/2022