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: Jan. 17, 2023

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: 01/17/2023 8:30AM until 2:00PM 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 another licensing inspector 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 #:	22VAC40-73-460-H
Description:	Based on resident record review, the facility failed to ensure that personal assistance and care were provided to each resident so that the needs of the resident are met, including bathing at least twice per week. EVIDENCE: 1. The documents ?skin monitoring: comprehensive CNA shower review?, provided by the facility during on-site inspection on 01/17/2023, from the dates of 12/01/2022 through 01/17/2023 for resident 13 contained documentation regarding bathing on the following dates: 12/08/2022 with a refusal, 01/02/2023 with a refusal, 01/10/2023 with a refusal, and 01/13/2023 with a refusal which indicated that the resident had not received a shower during this time period. 2. During the preliminary exit on 01/17/2023 regarding resident 13, there was no additional documentation provided by the facility regarding bathing/showers for resident 13 during on-site inspection on 01/17/2023. 3. This standard was previously cited on 07/15/2022 and 12/08/2022.
Plan of Correction:	1.One on One staff training to be completed regarding Violation and ADL?s. 2.All safe and secure showers will now be completed and signed off in the EMAR system for the supervisor in charge of the unit to document daily showers. 3. A weekly Audit of Safe and Secure Showers will be conducted by Wellness Director/ Administrator or Designee to assure compliance. This will be discussed no less then weekly in the Managers Meeting. 4. Completion Date- 02/25/2023
Standard #:	22VAC40-73-640-A
Description:	Based on medication cart audit, staff interview and resident record review, the facility failed to implement its medication management plan regarding methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The facility?s medication management plan states the following: ?Methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes: Each controlled substance will be tracked using a separate Controlled Medication Log which meets the requirements of state and federal narcotic enforcement agencies. At the end of each shift, the outgoing and incoming RN, LPN, or RMA authorized to administer medications, will count all controlled substances and sign the Controlled Medication Log verifying the count is accurate. 2. While performing a sample audit of narcotics in the medication cart in the safe, secure unit, one licensing inspector (LI) and staff 6 observed that the controlled drug record for resident 11?s lorazepam 0.5 mg tab, ?take one tablet by mouth at bedtime for anxiety?, indicated that there were nine pills in the pill card; however, upon review of its corresponding pill card, there were eight pills in the card. 3. Interview with staff 6 revealed that staff 7 forgot to complete the controlled drug record after dispensing the medication.
Plan of Correction:	1. Count was corrected with Wellness Director on day of inspection. 2. One on One Staff training and Counseling completed with Employee 6&7 to be completed by Wellness Director / Administrator regarding Medication Management Plan and expectations. 3. A four-hour required Refresher course will be conducted by a third party for the Facility on February 9th, 2023, and again is set for August 24th, 2023 4. Completion Date- 02/25/2023
Standard #:	22VAC40-73-660-B
Description:	Based on observation during a tour of the buildings and resident record review, the facility failed to ensure that a resident may be permitted to keep his own medication in an out-of-sight place in his room if the resident?s uniform assessment instrument (UAI) indicates that the resident is capable of self-administering medication. EVIDENCE: 1. The UAI for resident 4, dated 10/21/2022, indicates that the resident requires his medication to be administered by licensed medication staff. The record for resident 4 contained a physician?s order, dated 11/10/2022, for Nizoral shampoo to be used every Monday and Thursday. 2. During on-site inspection on 01/17/2023, one licensing inspector (LI) observed that the aforementioned medicated shampoo was sitting on the back of the toilet in resident 4?s bathroom; however, the physician?s order does not indicate that the shampoo can be kept in the resident?s room and that the resident may self-administer the shampoo. 3. This standard was previously cited on 10/20/2022 and 12/08/2022.
Plan of Correction:	1. Resident #4 had a complete room sweep conducted by Administrator and Wellness Director on day of inspection. 2. One on One Staff training with all RMAs regarding Medication Management Policy and expectations as well as required 4-hour refresher training to be completed by a third party on site for all RMAs on February 9th. 3. A meeting was conducted with the resident and family on January 20, 2023, to review policy and regulations on medications and chemicals in the facility. 4. Completion Date: 02/25/2022
Standard #:	22VAC40-73-680-B
Description:	Based on medication cart audit, resident record review and staff interview, the facility failed to ensure that a medication was in the pharmacy-issued container with the prescription label or direction label attached. EVIDENCE: 1. While performing a sample audit of narcotics in the medication cart in the safe, secure unit, one licensing inspector (LI) observed a plastic bag containing a brown pharmacy bottle which held a liquid substance; however, the information on the pharmacy label on the bottle was not legible and was missing components such as what the medication was, who the medication is for, and directions for administering medication. 2. Interview with staff 6 revealed that the bottle had been leaking which caused the information on the pharmacy label to wash off. Staff 6 indicated that the aforementioned medication belonged to resident 12 and was the resident?s prescribed as needed Oxycodone HCL 5 mg/ 5 ml; however, the LI could not make this determination from the condition of the label. 3. At approximately 9:32AM, one LI observed a small, round red pill by the white trash can in resident 5?s room with an inscription of 205 on one side and LS on the other side. The resident?s record contained a physician?s order for the aforementioned medication and it was also indicated on the resident?s December 2022 and January 2023 medication administration records. The pill was also observed by staff 3. 4. This standard was previously cited on 09/02/2022 and 10/20/2022.
Plan of Correction:	1. Administrator and Wellness Director completed room sweeps while inspectors were on site day of the inspection. 2. Wellness Nurse had contacted 3rd party provider regarding medication and need to follow medication management plan and a new medication was ordered prior to the day of inspection for delivery to follow the Medication Management Plan. Medication was delivered the evening of inspection. 3. One on One staff education to be completed with all current RMAs/Nurses regarding a review of medication management and expectations to be completed by Wellness Nurse or Administrator. 4. Medication Pass Observations to be completed no less than monthly on all RMAs for the next 6 months and then as periodically by Wellness Director or Administrator. 5. Completion Date- 02/25/2023
Standard #:	22VAC40-73-860-I
Description:	Based on observation during a tour of the buildings, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area. EVIDENCE: 1. At approximately 9:36 AM in the facility?s safe, secure unit, one licensing inspector (LI) observed a pair of scissors and a box of pushpins sitting inside of the nurses? station which were accessible by residents. This was also observed by staff 6. 2. In the facility?s assisted living building, one LI observed the following items: a container of Clorox disinfecting wipes located by the bathroom in resident 4?s room, a container of Clorox disinfecting wipes, a spray can of Lysol disinfecting spray, a spray can of Glade air freshener, and a container of Reliable citrus scent disinfectant spray in resident 5?s room, and two containers of Lysol toilet bowl cleaner in resident 10?s room. The aforementioned items were also noted by staff 3. 3. This standard was previously cited on 10/20/2022 and 12/08/2022.
Plan of Correction:	1. On day of inspection all items were removed with inspector during tour of facility. All items were removed from nurse?s station on day of inspection. 2. One on One Staff education to be completed regarding all violations that occurred on 01/17/2023. 3. Room Sweep assignments to be scheduled daily for all Managers on duty at least 4-5 times weekly during the morning meeting and checklist to be turned in after to Wellness Nurse or Administrator. 4. Completion Date 02/20/2023
Standard #:	22VAC40-73-870-A
Description:	Based on observation during a tour of the buildings, the facility failed to ensure that the interior and exterior of all buildings were maintained in good repair and kept clean. EVIDENCE: 1. At approximately 8:30AM, one licensing inspector (LI) observed that the counter between the dining room and the kitchen in the facility?s safe, secure unit, contained a large area of a pink sticky substance on the counter and down the wall below the counter and the aforementioned substance was still noted at 9:58 AM. 2. In the facility?s safe, secure unit, one LI observed several areas of a wet brown/yellow substance next to the resident?s bed in room 42. 3. At approximately 9:17AM, one LI observed that the bathroom in room 47 in the facility?s assisted living building contained a large brown substance on the floor and the trash can was full of trash. At approximately 12:02PM, the aforementioned issue was still present in the bathroom and was also observed by staff 3. 4. At approximately 9:19AM, one LI observed that the bathroom in room 45 in the facility?s assisted living building contained multiple dirty towels hanging on the towel rod and the shower curtain contained multiple areas of brown stains toward the bottom of the curtain. At approximately 12:04PM, the aforementioned issue was still present in the bathroom and was also observed by staff 3. 5. This standard was previously cited on 10/20/2022 and 12/08/2022.
Plan of Correction:	1. All areas sited was addressed during inspection while inspectors were on site. 2. One on One staff education to be given regarding all violations on the 01/17/2023 inspection will be conducted with every employee by Administrator or Wellness Director by 02/25/2023 3. Housekeeping Rounds will continue to occur daily by Administrator or Designee daily for compliance. 4. Completion Date- 02/25/2023