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: Oct. 20, 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 BUILDINGS AND GROU22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSND

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: 10/20/2022 9:00AM until 2:30PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A non-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 follow up for an inspection that required an intensive plan of correction (IPOC) that was issued to the facility on 08/26/2022, 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 #:	22VAC40-73-1110-B
Description:	Based on resident record review and staff interview, the facility failed to ensure that six months after placement of the resident in a safe, secure environment and annually thereafter, the licensee, administrator, or designee performed a review of the appropriateness of a resident?s continued residence in the special care unit. EVIDENCE: Resident 6 resides in the facility?s safe, secure unit. The record for resident 6 contained the initial ?approval for placement in special care unit? form which was completed on 11/18/2021 for the resident; however, the record did not contain documentation of the six month review for appropriateness for the resident. When questioned, staff 2 could not verify that the six month review had been completed.
Plan of Correction:	1.During inspection review Staff 2 was made aware of the findings of complaint and given the evidence at that time Staff 2 had only been employed for 2 days and was not aware of placement in chart of form. After receiving Violation Notice and review of chart for resident 6 completed with ISP/UAI coordinator the documentation for the 6-month placement was under the assessment tab and was signed by previous Administrator on 04/18/2022. This is the tab all assessments after initial are kept. 2. All records reviewed for proper documentation for the safe and secure unit. All records to be reviewed monthly for on-going compliance. 3. Completion Date 10/28/2022
Standard #:	22VAC40-73-150-B-6
Description:	Based on documentation and staff interview, the facility failed to ensure to not be operated by an acting administrator for no more than 90 days. EVIDENCE: Staff 1 was appointed as the facility?s acting administrator on 07/01/2022 for 90 days. The licensing inspector (LI) received an email from staff 2 that they were now the facility?s administrator of record as of 10/17/2022 therefore meaning that staff 1 was the facility?s acting administrator for longer than 90 days. Interview with staff 2 and 3 confirmed the aforementioned information was accurate.
Plan of Correction:	1.Facility has in place as of 10/17/2022 a Licensed Acting Administrator. 2.The facility like many will continue to recruit quickly for all positions and train staff that are able to stand in during the need of an acting administrator. 3.Administrator in place will receive or be encouraged to obtain the preceptor license to begin this process with other eligible employees. 4.Completion Date -10/17/2022
Standard #:	22VAC40-73-350-B
Description:	Based on resident record review, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender. EVIDENCE: Resident 1 was admitted to the facility on 07/31/2022; however, a Virginia state police sex offender registry search was not conducted for the resident until 08/01/2022.
Plan of Correction:	1.All files to have audit complete to ensure compliance with Sex offender search. 2.Administrator /Designee and DON or Wellness Nurse as well as Marketing Coordinator will review all prior admission paperwork prior to admissions going forward from 10/20/2022. 3.Checklist for all prior admissions will be established and signed by Administrator/Designee as well as Marketing Coordinator by 12/01/2022. This will be completed on all admission unless an emergency admission was to be presented to facility. 4.Completion Date- 12/01/2022
Standard #:	22VAC40-73-660-B
Description:	Based on observation during a tour of the facility?s physical plant and resident record review, the facility failed to ensure that for residents with medications in their rooms the uniform assessment instrument (UAI) indicated the residents are capable of self-administering medication. EVIDENCE: 1. At approximately 9:18AM, one licensing inspector (LI) observed a tube of Triamcinolone 0.1% cream on the bathroom sink in resident 1?s room. The public pay UAI for resident 1, dated 06/15/2022, indicated that the resident requires their medication to be administered/monitored by a lay person ?med tech on duty?. The record for resident 1 included a physician?s order, dated 04/11/2022 for Triamcinolone 0.1% cream apply topically to affected areas two times a day for treatment; however, the physician?s order does not indicate that the resident can self-administer the aforementioned medication and keep in their room. 2. At approximately 9:38AM, one LI observed a bottle of Pepto Bismol on the floor beside resident 2?s room. The private pay UAI for resident 2, dated 09/14/2022, indicated that the resident requires their medication to be administered/monitored by lay a person. The record for resident 2 did not contain a physician?s order for the resident to be able to keep Pepto Bismol in their room and self-administer.
Plan of Correction:	1.Administrator and all on site management team completed a facility tour of all rooms after on-site inspection on 10/20/2022 to ensure no OTC medications or prescription medications was located at bedside. 2.Wellness Nurse/DON/Administrator will review the need for self-administer medication order if needed for OTC medications on a case-by-case bases for residents. 3.Medication Management to be reviewed with all staff regarding the process of having OTC medications at bedside or in resident?s rooms by 12/02/2022. 4.Administrator/Designee will begin effective 10/24/2022 to have all management staff monitor areas of non-compliance and have random room sweeps 3-5 times a week following stand-up meetings. 5.Completion Date 11/05/2022
Standard #:	22VAC40-73-680-B
Description:	Based on observation during a tour of the facility?s physical plant, the facility failed to ensure medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. EVIDENCE: At approximately 9:25AM during on-site inspection on 10/20/2022, one licensing inspector (LI) observed a white, oblong pill with an inscription of 164 on one side and a ?G? inscribed on the other side on the floor in front of the nightstand in resident 3?s room. Interview with resident 3, in the presence of two licensing inspectors and staff 3, revealed that the aforementioned pill was hers.
Plan of Correction:	1.All RMAs/Nurses will have a medication refresher course completed by 12/01/2022. 2.Inservice to review medication management policy with all staff to be completed by 12/02/2022 3.Administrator/Designee to have all managers to continue with random room sweeps for compliance after morning stand-up meeting 3-5 times a week. 4.Completion Date- 12/01/2022
Standard #:	22VAC40-73-680-D
Description:	Based on observation during a tour of the facility?s physical plant, resident record review and resident interview, the facility failed to ensure medications were administered in accordance with the physician?s or other prescriber?s 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 record for resident 3 contained a physician?s order, dated 06/16/2022, for Carvedilol 12.5mg twice a day for hypertension, hold for systolic blood pressure less than 110 or heart rate less than 60. The October 2022 medication administration record (MAR) for resident 3 contained documentation at 8:00PM on 10/06/2022 that the resident?s blood pressure was 105/61; however, staff initials were present for administering the aforementioned medication. Staff initials were circled on the October 2022 MAR as not administering this medication at 8:00AM on 06/08/2022 with a notation on the MAR of ?doctors order?; however, resident 3?s blood pressure was documented as 116/82 and heart rate was documented as 67. The October 2022 MAR also contained staff initials that are circled as not administering this medication at 8:00PM on 06/08/2022 with a notation on the MAR of ?doctors order? but resident 3?s blood pressure was documented as 112/72 and heart rate was documented as 60. 2. Resident 5 was admitted to the facility on 07/31/2022. The record for resident 5 contained signed physician?s orders, dated 07/28/2022, for Calcium-Vitamin D one tablet daily and a Multivitamin one tablet daily. During on-site inspection on 10/20/2022, the two aforementioned medications were not documented on the resident?s September and October 2022 medication administration records (MARs) and were also not located in the facility. The record for the resident did not contain a physician?s order that the two medications had been discontinued. This was also verified by staff 3 and 5.
Plan of Correction:	1.The resident files for #3 and #5 will have a MD review on the next visit and MD will update orders as needed for corrections needed. 2.PCP to have a new PA to round and review orders for accuracy with Wellness Nurse/DON/Administrator. All new orders will be reviewed with rounding Wellness nurse and Administrator/Designee following rounding with PA/MD. 3.10 MARS/TARS to be reviewed by Wellness Nurse /Administrator or Designee each week for accuracy. 4.All MAR orders to be fully reviewed by Wellness Nurse/DON/Administrator or Designee by Dec 1, 2022. 5.Will contact Pharmacy to request any additional assistance for monitoring as well. 6.Completion Date- 12/01/2022
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, medication cart audit, and staff interview, the facility failed to ensure all required documentation was on the medication administration record (MAR). EVIDENCE: The record for resident 5 contained the following three physician?s orders for ?Zyrtec 10MG daily for head congestion for one week? dated 08/26/2022, 09/29/2022 and 10/17/2022. The September and October 2022 medication administration records (MARs) for resident 5 contained staff signatures that the aforementioned medication was administered daily at 8:00AM (except October 7, 2022 through October 13 due to the resident being hospitalized); however, interview with staff 3 indicated that the medication was only administered by staff according to the physician?s instructions on 08/26/2022 order for seven days from 08/26/2022 until 09/02/2022.
Plan of Correction:	1.MAR to Cart Audit to be complete by 12/15/2022 on all medication carts by Wellness Nurse/ Administrator or Designee. 2.Pharmacy will be contacted by 12/01/2022 to schedule a follow-up Audit within 60 days. 3.RMA/Nurse education to be reviewed during refresher course. Wellness Nurse/DON/ Administrator or designee to have a 2-person review of new orders placed in MAR system after completion by 12/01/2022. 4.Completion Date ? See above
Standard #:	22VAC40-73-860-I
Description:	Based on observation during a tour of the facility?s physical plant, the facility failed to ensure cleaning supplies and other hazardous materials were stored in a locked area. EVIDENCE: 1. At approximately 9:45AM during on-site inspection on 10/20/2022, one licensing inspector (LI) noted a bottle of Medline Skintegrity wound cleaner sitting on a rolling cart in C hall and at 9:51AM one LI noted the door to room 41 to be unlocked and it contained a bottle of Goo Gone latex paint clean up. 2. At approximately 9:56AM, one LI noted the door to the laundry room to be unlocked and unattended in the assisted living building. The LI noted a bottle of Windex, a container of Pure Bright bleach, and a bottle of Persil Proclean laundry detergent that contained resident 1?s name. 3. At approximately 11:08AM, one LI noted that room 14 was unlocked and contained a spray bottle of Great Value disinfectant spray and a bottle of Swan nail polish remover. 4. At approximately 9:00 AM, one LI noted the laundry room door was propped open in the facility?s safe, secure unit and the LI observed a container of Purex laundry detergent and a bottle of blue dish detergent on the shelf in the laundry room. 5. At approximately 9:02AM, one LI entered the unlocked laundry storage room and observed a tube of Loctite Construction Adhesive sitting on a shelf in the storage room in the facility?s safe, secure unit.
Plan of Correction:	1.Laundry Storage room Keypad battery replaced on day of on-site inspection at approximately 11:00am. 2.Monthly log to be maintained by Maintenance on the changeout of batteries monthly in high traffic areas that have keypad locks in place to include the housekeeping and laundry areas. Administrator/Designee will review monthly and sign log for accuracy. 3.Housekeeping to continue to complete twice weekly rounds and all managers and or staff to complete rounds/room sweeps 3-5 times a week after stand-up meeting to ensure all areas are properly secured and chemicals are placed in designated areas in both AL and MC areas. 4.The Safe and Secure Units laundry room had a lock keypad installed on 10/21/2022 to maintain safety going forward. 5.Safe and Secure unit to have rounds completed for ensuring compliance 5 times a week to be preformed by any staff member and or Administrator or Designee at least 5 times weekly to be in place by 12/01/2022 6.Inservice Education with all staff regarding Chemicals and Safety in the Safe and Secure Unit and AL by 12/01/2022. 7.Completion Date -12/01/2022
Standard #:	22VAC40-73-870-A
Description:	Based on observation during a tour of the facility?s physical plant, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. EVIDENCE: 1. At approximately 9:51AM during on-site inspection on 10/20/2022, one licensing inspector (LI) noted that the bathroom floor in room 13 in the facility?s safe, secure unit contained a large, brown stain around and in front of the toilet. Staff 5 was observed cleaning the floor during this time and interview with staff 5 revealed that they had not been able to remove the stain during previous cleanings. 2. At approximately 9:55AM, one LI noted that the carpet in the hallway outside of multiple residents? room contained numerous stains. 3. At approximately 9:17AM, one LI noted that the inside of the toilet bowl in resident 1?s bathroom contained a large stain.
Plan of Correction:	1.The floor in bathroom of room E10 was well cleaned and still had a noted darkened area. The material has been ordered and will be replace by November 15, 2022. A round after the on-site visit did not show a area in the floor of 13 as noted in the notice. 2. Rounds of all occupied rooms will be completed once weekly for a list of any needed repairs or needed cleaning by maintenance /Housekeeping and Administrator or designee. 3. Carpet cleaning schedule to be made for a weekly cleaning by housekeeping in Safe and Secure Unit by 12/01/2022 and plans for removal and replacement will be conducted by cooperate. 4.Cleaning Schedule for Housekeeping and Nursing staff to be in place at both AL and safe secure units to include housekeeping measures to be completed and in place by 12/01/2022. 5. Completion Date- 12/02/2022
Standard #:	22VAC40-73-870-B
Description:	Based on observation during a tour of the facility?s physical plant, the facility failed to ensure all buildings were well-ventilated and free from foul, stale, and musty odors. EVIDENCE: During on-site inspection on 10/20/2022, one licensing inspector (LI) noted foul odors emanating from rooms 10 and 13 located in the facility?s safe, secure building.
Plan of Correction:	1.Cleaning Schedule to be created for housekeeping and nursing for both AL and safe and secure unit to be in place by 12/01/2022. 2.Management staff to do rounds 3-5 times a week after stand-up meeting to ensure areas are free from odor to be completed no later than 12/01/2022. 3.Completion Date- 12/01/2022
Standard #:	22VAC40-73-870-D
Description:	Based on observation during a tour of the facility?s physical plant, the facility failed to ensure that buildings were kept free of infestations of insects. EVIDENCE: From approximately 9:00 AM to 10:50 AM during on-site inspection on 10/20/2022, one licensing inspector (LI) noted numerous insect carcasses in multiple residents? rooms as well as in common areas and in the three hallways located in the facility?s safe, secure unit.
Plan of Correction:	1.All areas of the safe and secure building will have twice weekly inspections by Housekeeping and Administrator or Designee to be completed no later than 12/01/2022. 2.Training for all safe and secure staff on housekeeping measures and scheduled housekeeping for nursing and housekeeping to be completed by 12/01/2022. 3.Completion Date- 12/01/2022
Standard #:	22VAC40-80-120-E-3
Description:	Based on observation during a tour of the facility?s physical plant, the facility failed to have posted on the premises of the facility the notice of the commissioner?s intent to revoke or deny renewal of the facility?s license to advise consumers of serious or persistent violations. EVIDENCE: The document, notice of intent to deny renewal application for a license, dated 09/07/2022, was not posted in the facility during on-site inspection on 10/20/2022.
Plan of Correction:	1.Notice of intent was placed in required areas on 10/20/2022 after exit interview from on-site inspection. 2. Administrator/Designee will post all inspection required paperwork upon receipt as well as day of inspection going forward from 10/20/2022 3. Completion Date- 10/20/2022