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: March 8, 2023 and March 14, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 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(s) of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 03/08/2023 8:30AM through 6:30PM in conjunction with two other licensing inspectors and on 03/14/2023 10:15AM through 2:30PM under the supervision of the Licensing Administrator. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. An unannounced monitoring inspection was conducted. The focus of the inspection was to determine whether the provider had corrected or is in the process of correcting previously cited violations in the areas of standards referenced above. This inspection found the provider to demonstrate noncompliance with standards not identified in the plan of correction. 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 #:	22VAC40-73-1110-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that prior to admitting a resident with a serious cognitive impairment due to a primary diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee determined whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and placed in the resident?s file. EVIDENCE: The records for residents 11, 12 and 13 did not contain documentation that a determination by the licensee, administrator, or designee was completed on the residents that placement in the special care unit is appropriate for residents 11, 12 and 13. Interview with staff 1 confirmed this is accurate.
Plan of Correction:	1. Documentation provided to inspector for approval and information reviewed. 2. Form completed for all new Residents in safe and secure unit on 03/09/2023. 3. Documentation in place and will be completed on all new admissions to the safe and secure unit. 4. Completion Date- 04/30/2023
Standard #:	22VAC40-73-120-A
Description:	Based on staff record review, staff interview and document review, the facility failed to ensure that orientation and training for new employees occurred within the first seven working days of employment. EVIDENCE: 1. The record for staff 11 did not contain documentation that the staff person has received orientation and training that is required within the first seven working days of employment. Interview with staff 1 expressed that this staff person?s date of hire was 02/21/2023. 2. The record for staff 6 did not contain documentation that the staff person has received orientation and training that is required within the first seven working days of employment. A list of current staff provided by staff 14 during on-site inspection on 03/08/2023 indicated that staff 6?s date of hire was 12/16/2022.
Plan of Correction:	1. Information requested during exit interview and submitted per request after exiting due to not having the opportunity to produce information during the inspection from lack of request from inspectors on site. 2. Inspectors on site was aware that BOM had quit without notice and that ED was actively working that position and ample time to supply needed information was not given. 3. BOM hired and will start on 03/21/2023. 4. BOM and ED will continue prior POC audits as scheduled from prior POC that has not been followed up on from submission or ?monitoring visits.? 5. Completion Date- 04/30/2023
Standard #:	22VAC40-73-250-C
Description:	Based on staff record review, the facility failed to ensure all required information was included in staff records. EVIDENCE: 1. The record for staff 2 hired on 02/15/2023 did not contain verification that this employee has received a copy of their current job description. 2. The records for staff persons 5, 6, 7, 8, 10 and 11 did not contain documentation of these employees? date of hire. Also, the records did not contain verification that these employees have received a copy of their current job description. 3. This standard was previously cited on 12/08/2022.
Plan of Correction:	1. Information requested during exit interview and submitted per request after exiting due to inspector needing to leave instead of having the opportunity to submit during the inspection due to lack of request from inspectors on site. 2. Inspectors on site was aware that BOM had quit without notice and that ED was actively working that position as well and ample time to supply any additional information was not provided or asked for during inspection. 3. BOM and ED will continue prior POC audits as scheduled from prior POC that has not been followed up on from submission or during any ?monitoring visits.? 4. Completion -04/30/2023
Standard #:	22VAC40-73-250-D
Description:	Based on staff record review and document review, the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility submitted the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. EVIDENCE: 1. The record for staff 5, date of hire 01/23/2023, contained a TB risk assessment that was dated 01/23/2023; however, the form itself was incomplete. 2. The record for staff 9, date of hire 02/03/2023, contained a TB risk assessment that was completed; however, there was no date of completion. 3. During on-site inspection on 03/08/2023, the record for staff 10, did not contain the results of a TB risk assessment.
Plan of Correction:	1. Staff file 5,9 corrected with MD visit. Staff information 10 once again submitted after reviewing due to not having ample time or request during initial inspection per inspector?s request. 2. Inspectors on site was aware that BOM had quit without notice and that ED was actively working that position as well and ample time to supply any additional information was not provided or asked for during inspection. 3. BOM and ED will continue prior POC audits as scheduled from prior POC that has not been followed up on from submission or on any ?monitoring visits?. 4. Completion Date-04/30/2023
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review, the facility failed to ensure that the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative. EVIDENCE: The ISP for resident 13, dated 11/01/2022, was not signed by the resident or legal representative.
Plan of Correction:	1. The ISP for Resident 13 has since been signed. 2. All ISPs will be mailed and emailed to all resident?s legal representative that have emails provided. 3. If an ISP has not been returned to the facility signed the facility will then send the legal representative a certified copy of the ISP and the log will be kept with the ISP. 4. Completion Date ? 05/31/2023
Standard #:	22VAC40-73-640-A
Description:	Based on observations of the facility?s medication carts and document review, the facility failed to ensure implementation of their medication management plan in regard to methods to prevent the use of outdated, damaged or contaminated medications. EVIDENCE: 1. The facility medication management plan provided to the licensing inspector (LI) by staff 1 on the day of inspection has documentation that ?Medications that have been discontinued or found to be contaminated, damaged, and/or out dated should be disposed of properly?. The medication management plan also has documentation ?check carts to ensure all medications are labeled properly (open dates)?. 2. The following medications were observed by the LI to be opened on the medication carts but did not contain a date of opening to ensure disposal per manufacturer?s instructions: A Basaglar Insulin Pen was open on the D-Hall cart for resident 1. The pen did not contain a date that it was opened. Manufacturer?s instructions are to discard this medication 28 days after opening. A Lantus Solostar Insulin Pen was open on A-Hall cart for resident 8. The pen did not contain a date that it was opened. Manufacturer?s instructions are to discard this medication 28 days after opening. A Lantus Solostar Insulin Pen was open on B-Hall cart for resident 9. The pen did not contain a date that it was opened. Manufacturer?s instructions are to discard this medication 28 days after opening. A Humulin 70/30 Insulin Kwik Pen was open on C-Hall cart for resident 10. The pen did not contain a date that it was opened. Manufacturer?s instructions are to discard this medication 28 days after opening. 3. This standard was previously cited on 01/17/2023.
Plan of Correction:	1. Wellness Nurse Corrected during monitoring visit. 2. All carts audited on 03/09/2023 and any corrections needed and 1:1 training with newer staff to ensure awareness of labeling medication with a open date. 3. Weekly med cart audits will continue as well as Medication Observations on staff. 4. Completion Date: 04/30/2023
Standard #:	22VAC40-73-660-A-3
Description:	Based on observations of the facility medication carts, the facility failed to ensure that individuals responsible for medication administration keep the keys to medication carts/storage areas on their person. EVIDENCE: 1. At approximately 8:34AM on day of inspection, two licensing inspectors (LIs) and staff 1 observed a set of keys on a green key ring that was labeled ?C? lying out on top of the D-Hall medication cart, which was unattended at the time of this observation. Staff 1 removed the keys from the top of the medication cart. 2. Interview with staff 2 at 8:50AM on the day of inspection revealed that the keys belonged to the registered medication aide (RMA) administering medications to residents on the C-Hall and D-Hall. Staff 2 expressed that the keys lying on top of the D-Hall medication cart were keys to the C-Hall medication cart and that the keys were returned to her.
Plan of Correction:	1. ED corrected on site and placed keys in possession and returned to staff 2. 2. Wellness Director placed keys for carts C&D on lanyard to help assist staff to follow medication policy. As well as had a 1:1 coaching moment with a new employee that was working the area on her own after orientation. 3. Wellness Director and ED will continue spot checks and medication observation passes as stated and not viewed during ?monitoring? inspection. 4. This is in place and will continue. Completion Date- 04/30/2023
Standard #:	22VAC40-73-660-B
Description:	Based on observation, resident record review and resident interview, the facility failed to ensure residents may be permitted to keep his own medication in an out-of-sight place in his room if the uniform assessment instrument (UAI) has indicated that the residents are capable of self-administering medication. EVIDENCE: 1. At approximately 9:12AM during on-site inspection, one licensing inspector (LI) observed a bottle of Genteal tears lubricated eye drops, a bottle of Systane lubricant eye drops and container of Genteal tears lubricant eye gel on resident 5?s bathroom sink. The LI interviewed resident 5 and resident 5 informed the LI that she uses the eye drops herself and that staff do not administer the eye drops that are located on her bathroom sink. The record for resident 5 does not contain any physician?s orders that the resident may have and self-administer the aforementioned eye drops and eye gel. The UAI for resident 5, dated 03/02/2023, indicates that the resident requires her medications to be administered/monitored by a registered medication aide (RMA) and/or a nurse. 3. This standard was previously cited on 10/20/2022, 12/08/2022 and 01/17/2023.
Plan of Correction:	1. All medications removed by Wellness Nurse on day of inspection. 2. A memo will be attached with Resident Agreement on all new admissions for POA and/or Residents signature to review policy and procedures regarding OTC medications. 3. April Resident Council shall have a discussion and have all Residents sign regarding policy and procedure and a meeting with all AL residents will be conducted 1:1 to discuss regulation. 4. Completion Date-04/30/2023
Standard #:	22VAC40-73-680-B
Description:	Based on observation during a tour of the facility?s buildings, the facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label attached, until administered to residents. EVIDENCE: 1. At approximately 11:10AM in the facility?s memory care unit during on-site inspection on 03/08/2023, one licensing inspector (LI) observed a small white round pill inscribed with ?34? on the floor under the menu board in the dining room area of the memory care unit. In addition, at approximately 11:24AM in the facility?s memory care unit, the same LI observed a small orange-pink pill in the floor near the headboard of the bed in room 3. 2. At approximately 1:32PM during on-site visit on 03/14/2023 in the facility?s assisted living building, one LI and Collateral 1 noted a white round pill inscribed with ?058? lying along the threshold into resident 7?s room. It was verified by the LI and staff 1 that the pill was Prednisone 5MG and that resident 7 does have a current physician?s order for this medication every day. 3. This standard was previously cited on 09/02/2022, 10/20/2022 and 01/17/2023.
Plan of Correction:	1. Inspector brought a possible 2 of 3 to a actual qualify staff member to dispose of per medication management plan and ED or Wellness Director on exit was not given pictures or any other proof. Unsure of the disposal method but after exit room and building sweep had no deficiencies. 2. Floor will continue to be swept daily during environmental rounds and this has been noted to be taking place during inspectors entrance on occasions. 3. Environmental Rounds will continue 5 times a weekly at a minimum by 1 staff member and has not been reviewed during ?monitoring ? visits but will continue as stated in other POC. 4. Completion Date 04/30/2023
Standard #:	22VAC40-73-680-D
Description:	Based on observations of the facility medication carts, observation of the morning medication pass, review of resident medication administration records (MARs) and resident interview, the facility failed to ensure that medications were administered in accordance with physicians? instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. The February and March 2023 MAR for resident 1 has a physician order for Basaglar Insulin, 40units SQ twice a day. Hold for FBS (fasting blood sugar) less than 150. The MAR has documentation of the residents 8AM fasting blood sugar being 149 on 02/04/2023 and 115 at 8AM on 03/08/2023, which require the medication to be held per physician orders. Staff initials are present as administering the medication for both days. 2. The uniform assessment instrument (UAI), dated 09/22/2022, for resident 3 has documentation that the facility administers this resident?s medications. The individualized service plan (ISP), dated 09/22/2022, has documentation under medication administration that ?A Registered Medication Aide/Nurse will administer medications per MD orders to resident. RMA/Nurse will ensure all meds were taken and swallowed before exiting room. Resident will receive all medications in a timely manner to include correct medications, dose, route, time as ordered by MD. Follow MD orders and crush applicable medications and mix with food substance (yogurt, applesauce, pudding) as needed. Resident is known to hoard medications?. During the morning medication pass observations conducted on the day of inspection it was observed by the LI and staff 3 that resident 3?s prescribed medications Advair Discus, Spiriva and Symbcort Inhalers were not on the A-Hall medication cart but the medication box with the pharmacy label was. Interview with resident 3 expressed that staff give him his inhalers and he keeps them in his room and uses them himself. The current medication aide curriculum revised by the Virginia Board of Nursing in 2022 has documentation on page 38 ?Stay with client until mediations have been consumed?. 1. The February and March 2023 MAR for resident 7 has staff initials who are RMA?s for administering the prescribed medication Trulicity 0.75mg/0.5ml Pen, inject sq 0.5ml=0.75mg once weekly on Fridays for DM. The current medication aide curriculum revised by the Virginia Board of Nursing in 2022 has documentation on page 53 that ?Non-Insulin Injections a. medication aides may not administer pursuant to 18VAC90-60-110(B)(5)?. 2. This standard was previously cited on 07/15/2022 and 10/20/2022.
Plan of Correction:	1. MD notified after exit as inspector was at bedside with staff number 2 when insulin was given and per notice it was at ?8am?. Inspector never reported the medication error that was conducted with inspector beside staff member until exit. Staff number 2 was completely nervous due to the intimidation that occurs once the inspectors enter and continue to make staff feel intimidated. Resident had no issues with error. 2. Resident #3 is on notice as our inspectors have been made aware due to non-compliance and along with the inspectors, we have had no assistance in 4 months to attempt to find adequate placement. 3. Medication error report completed and 1:1 counseling with new employee conducted after exit when Wellness Nurse and ED was made aware of 8 am medication error by inspector. 4. All Trulicity orders will now be administered by nursing staff on Fridays. My suggestion would be to ensure all facilities are aware and can make changes as necessary so that our community?s as well as Inspectors continue to work together to obtain the best care for our residents.
Standard #:	22VAC40-73-680-E
Description:	Based on observation, staff interview, and resident record review, the facility failed to ensure that medical procedures and treatments ordered by a physician or other prescriber were provided according to his instructions and documented. EVIDENCE: 1. Resident 13 has physician?s orders for Tubi-grip stockings to be applied to the resident?s legs every morning and removed every evening at bedtime. 2. The March 2023 medication administration record (MAR) for resident 13 indicates that resident 13 had her stockings applied at 10:00 AM on the date of inspection; however, one licensing inspector (LI) noted that from 8:50 AM until 12:30 PM, that resident 13 did not have on Tubi-grip stockings, and both staff persons 15 and 16 stated that they had not applied her stockings that morning. At approximately 1:20PM, two other LIs noted that resident 13 still not did have on Tubi-grip stockings and this was observed as well by staff person 16. 3. This standard was previously cited on 12/08/2022.
Plan of Correction:	1. Inspectors noted during exit interview that this was Ted Hose order and proceed to make us aware she had something on her L knee area that was in fact the Tubi-grip that was stated not to be on this was verify by Wellness nurse and ED after exit. Resident had order for Tubi-grips not Ted hose. This order was Discontinue on day of inspection due to resident being non-compliant with keeping Tubi-grips in place. 2. All carts audited after information given during inspection and corrections completed at that time. 2.Wellness Nurse will review all Secured unit orders for compliance by 04/30/2023 and as stated on prior POC and not followed up on ?monitoring visit? weekly medication cart audits will continue. 3. Completion Date- 04/30/2023
Standard #:	22VAC40-73-680-K
Description:	Based on observations of the facility medication carts and resident medication administration records (MARs), the facility failed to ensure that the use of PRN (as-needed) medications is prohibited, unless one or more of the following conditions exist: the resident is capable of determining when the medication is needed; licensed health care professionals administer PRN medication; or if medication aides administer PRN medication, the resident?s physician or other prescriber?s order shall include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist. EVIDENCE: The A-Hall medication cart contained the prescribed medication Narcan for resident 7. The record for resident 7 has a physician?s order for Narcan 4mg nasal spray, administer 1 spray in either nostril for suspected opioid overdose. May repeat every 3 minutes as needed, alternating nostrils for each spray, call 911 immediately. The order does not include symptoms that indicate the use of the medication which would be required as the facility employs RMA?s who administer PRN medications.
Plan of Correction:	1. MD notified on day of inspection and order was discontinued before exit interview was complete. 2. As stated in prior POC Wellness Nurse will continue Chart/MAR/Cart audits that continue to be conducted per prior POC. 3. Effective- Has been in place but not followed up on.
Standard #:	22VAC40-73-860-I
Description:	Based on observation of the facility?s buildings, the facility failed to ensure that cleaning supplies and other hazardous materials are stored in a locked area. EVIDENCE: 1. At approximately 9:01AM in the facility?s assisted living building during inspection on 03/08/2023, the door to room 42 was unlocked and one LI noted a spray bottle of McKesson dermal wound cleanser, a bottle of Dakin?s wound antimicrobial cleanser, and two bottles of Hibiclen?s antiseptic/antimicrobial skin cleanser. 2. At approximately 9:23AM in the facility?s assisted living building, one LI noted a small, plastic cup of a white unknown substance on the bedside table in resident 15?s room. 3. At approximately 9:24AM in the facility?s assisted living building, one LI noted a container of Foca laundry detergent on the back of the toilet in resident 16?s room. 4. At approximately 10:20AM during on-site visit on 03/14/2023 in the facility?s assisted living building, one LI noted that the door to the janitor?s closet near ?D? hall was unlocked and contained multiple bottles of chemicals and cleaners. This was also observed by staff 1 and Collateral 1. 5. This standard was previously cited on 10/20/2022, 12/08/2022 and 01/17/2023.
Plan of Correction:	1. Inspectors entered almost every room in both buildings including known empty rooms. During normal ?inspection and or monitoring? this is not typical. Once they completed the entire building sweep our managers removed all hazardous noted items. 2. A keypad was ordered for the last housekeeping door. 3. Environmental rounds as per previous POC 5 times a week and 1:1 counseling completed regarding ensuring all empty rooms are locked to ensure safety. Inspectors viewed by walking with Maintenance the empty and remodeled rooms and they stated gratitude on improvement. 4. Completion Date- 04/30/2023
Standard #:	22VAC40-73-870-B
Description:	Based on observation during a tour of the facility?s buildings, the facility failed to ensure that all buildings were well-ventilated and free from foul, stale, and musty odors. EVIDENCE: 1. At approximately 8:50AM until 12:30PM during on-site inspection on 03/08/2023, one licensing inspector (LI) detected a foul odor throughout the memory care unit common area and down the hallway that contained resident rooms. When two other LIs entered the memory care unit at approximately 1:20PM, the same odor was noted. 2. This standard was previously cited on 07/15/2022, 10/20/2022, and 12/08/2022.
Plan of Correction:	1. Inspectors stated on exit that a ?musty? not foul odor was present during inspection this was not noted on prior inspection and the inspector had stated that they were impressed. No staff noted the ?musty? smell and ED and Housekeeping manager completed round prior to arrival of inspectors. 2. Carpet cleaning continues to be completed 3 times a week and environmental checks at least 5 times a week that was placed on prior POC that continues to not be followed up on with ?monitoring? visits. 3. Completion Date- 02/25/2023