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: Yes

Areas Reviewed:

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 BUILDINGS AND GROUND 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 9:00AM until 3:15PM and one inspection on-site on 12/17/2022 from 6:55AM until 7:10AM. 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 12/05/2022 regarding allegations in the areas of: personnel, staffing and supervision, admission, retention and discharge of residents, resident care and related services and buildings and grounds. 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, personnel, and buildings and grounds. 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 #:	22VAC40-73-250-C
Complaint related:	No
Description:	Based on staff record review and staff interview, the facility failed to ensure a record was established for a staff person. EVIDENCE: Based on observations during a tour of the building, staff interviews and staff record review, the facility failed to ensure that a staff record was established for all employees. EVIDENCE: During a tour of the facility physical plant staff 1, who was noted to be wearing a facility name badge, was observed preforming maintenance duties in the facility. A review of staff records noted that this employee did not have a staff record containing all required information. During an interview with staff 2 on the day of inspection, it was expressed that staff 1 was hired as a contractor to preform maintenance duties in the facility for a 90 day trial basis. Staff 2 expressed that the facility did not have documentation of a contract with this employee.
Plan of Correction:	1. Staff 1 was hired as an employee and an employee file was created. 2. All Contractor files will be audited by Business Office Manager to ensure proper documentation and contract is in place for compliance. 3. Business Office Manager in-service on staff/contract files and required documentation with Regional Oversight to be given on any new contract files. 4. Completion Date- 01/15/2023
Standard #:	22VAC40-73-460-H
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that residents personal assistance and care as necessary, in regarding to bathing at least twice a week, was met. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 2, dated 03/25/2022, indicated that the resident requires mechanical and physical human assistance with bathing and the individualized service plan (ISP) for the resident, dated 03/25/2022, indicated that staff will provide the resident complete assistance with bathing and getting in/out of the shower safely while encouraging the resident to participate as able while using the shower bench and grab bars. During on-site inspection, the facility produced documentation that resident 2 had only received four showers from 11/01/2022 through 12/08/2022. 2. The uniform assessment instrument (UAI) for resident 3, dated 10/24/2022, indicated that the resident requires mechanical and physical human assistance with bathing and the individualized service plan (ISP) for the resident, dated 10/25/2022, indicated that staff will provide the resident complete assistance with bathing and getting in/out of the shower safely while encouraging the resident to participate as able while using the shower bench and grab bars. During on-site inspection, the facility produced documentation that resident 3 had only received three showers from 11/01/2022 through 12/08/2022.
Plan of Correction:	1. Staff in-service to be completed regarding shower sheets and completion as well as the required documentation to be completed by nursing staff. 2. ISP/UAI to have audit completed to ensure accuracy. 3. DON/Designee and shift supervisor to review shower sheets for completion weekly and DON/Administrator or designee to complete monthly audits to ensure sheets have been completed for the month. 4. Completion Date- 01/15/2023
Standard #:	22VAC40-73-670-1
Complaint related:	Yes
Description:	Based on a review of medication administration records (MARs), staff record review and staff interviews, the facility failed to ensure that staff who are responsible for the administration of medications were licensed by the Commonwealth of Virginia to administer medications. EVIDENCE: 1. The November and December 2022 MAR?s for resident 4 has staff 4?s initials for the administration of the residents 8:00PM medications on 11/30/2022 and 12/02/2022. The December 2022 MAR for resident 3 has staff 4?s initials for the administration of the residents 8:00PM medications on 12/05/2022. 2. The facility provided documentation of a ?Eligibility to Test/Authorization to Practice? letter dated 09/21/2022 for staff 4. The third paragraph of the letter has a sentence that states ?You may practice in Virginia for a period not to exceed ninety (90) days from the completion of your nursing education program and the receipt of the results of your first licensing examination?. A phone call held on 12/15/2022 with collateral 1 clarified that an LPN-Applicant has 90 days from the date that they completed their nursing education program to practice as an LPN- Applicant and not 90 days from the date documented on the ?Eligibility to Test/Authorization to Practice? letter. 3. An interview conducted on the day of inspection with staff 4 expressed that the last day of their nursing education program was completed on 08/15/2022, which would have allowed this employee to practice as an LPN-Applicant up until 11/15/2022.
Plan of Correction:	1. Staff member 4 called Board of Nursing on site during inspection to verify information. Staff 4 was given in correct information during the phone call. 2. Staff 4 was removed from the schedule until pending testing date. 3. Business Office Manager/ Administrator will contact Board of Nursing to have education on regulations for LPN-A and clear understanding of the information on any letter presented for LPN-A applicants going forward. 4. Completion (Date- 01/15/2023
Standard #:	22VAC40-73-870-A
Complaint related:	No
Description:	Based on observation during a tour of the buildings, the facility failed to ensure the interior of the buildings were kept clean and free of rubbish. EVIDENCE: At approximately 9:29AM, two licensing inspectors (LIs) observed a sticky, medium sized red stain on the floor in front of the bedside table and multiple used cups and stains on the bedside table in resident 1?s room. Also in resident 1?s bathroom there was a small spill on the bathroom floor and the shower chair in the shower contained small brown stains. The two LIs observed one used blood glucose test strip in the hall in front of room D71 and one in the hall in front of room A43.
Plan of Correction:	1. All managers completed a room/building sweep to address housekeeping needs on completion of inspection on 12/08/2022. 2. Inservice for all Housekeeping staff /Nursing Staff regarding expectations as well as new cleaning schedule and daily assignments. Administrator and /or designee to continue recruiting efforts to build housekeeping department. 3. Environmental room checks to be completed no less than daily by administrator or designee. Findings to be reviewed and noted on daily stand-up agenda. 4. Completion Date- 01/15/2023
Standard #:	22VAC40-73-870-B
Complaint related:	No
Description:	Based on observation during a tour of the buildings, the facility failed to ensure all buildings were well-ventilated and free from foul, stale, and musty odors. EVIDENCE: Upon entering the facility?s safe, secure unit, one licensing inspector (LI) noted an overwhelming foul odor which continued to linger throughout the facility while the LI was present in the unit.
Plan of Correction:	1. Housekeeping sent to address issues on day of inspection of 12/08/2022. 2. Inservice for all Housekeeping Staff will be completed to review expectations as well as new cleaning schedule with daily assignments put in place. Administrator and/or Designee will continue recruiting efforts to build the housekeeping department. 3. Environmental room checks to be completed no less than daily by administrator or designee. Findings to be reviewed and noted on daily stand-up agenda. Regional Oversight to be conducted every 30-45 days. 4. Completion Date 01/15/2023
Standard #:	22VAC40-73-870-B
Complaint related:	No
Description:	Based on observation during a tour of the buildings, the facility failed to ensure all buildings were well-ventilated and free from foul, stale, and musty odors. EVIDENCE: Upon entering the facility?s safe, secure unit, one licensing inspector (LI) noted an overwhelming foul odor which continued to linger throughout the facility while the LI was present in the unit.
Plan of Correction:	1. Housekeeping sent to address issues on day of inspection of 12/08/2022. 2. Inservice for all Housekeeping Staff will be completed to review expectations as well as new cleaning schedule with daily assignments put in place. Administrator and/or Designee will continue recruiting efforts to build the housekeeping department. 3. Environmental room checks to be completed no less than daily by administrator or designee. Findings to be reviewed and noted on daily stand-up agenda. Regional Oversight to be conducted every 30-45 days. 4. Completion Date 01/15/2023