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: July 25, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUNDS

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/25/2024 9:30AM until 1:30PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 60 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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 #:	22VAC40-73-640-A
Description:	Based on an audit of medication carts and resident record review, the facility failed to ensure to implement its medication management plan in regard to methods to prevent the use of outdated, damaged, or contaminated medications. EVIDENCE: 1. The record for resident 2 contains a signed physician?s order, dated 05/15/2024, for latanoprost eye drops instill one drop into both eyes at bedtime for glaucoma, store in refrigerator until opened, stable for 6 weeks at room temperature. Manufacturer?s instructions for latanoprost eye drops state that the eye drops are good for 6 weeks once opened. 2. During the A-hall medication cart audit, it was noted by the licensing inspector (LI) and staff person 2 that the opened latanoprost eye drops in the cart for resident 2 did not contain a date of when the eye drops had been opened by staff. 3. The facility?s medication management plan states that its methods to prevent the use of outdated, damaged or contaminated medications is that medications that have been discontinued or found to be contaminated, damaged, and/or outdated should be disposed of properly. Interview with staff person 1 indicated that staff are to date medications that have an expiration date once they are opened, such as eye drops and insulin pens, with the date they are opened to ensure residents do not receive expired medications.
Plan of Correction:	? Open date for eye drops for resident #2 was clarified and corrected on 7/25/24. ? Mandatory all staff meeting conducted on 8/12-8/13/24. Inclusive of all RMAs in attendance to review medication management violations during 7/25/24 site monitoring visit. ? 4-hour virtual training conducted on 8/8/24 by contracted pharmacy nurse. Agenda inclusive of medication management standards. Attached signature sheet for RMAs in attendance. ? Comprehensive audit of all medication carts completed by nurse designee on 7/25- 7/26/24. All pharmaceuticals in need of open dates were noted to be in compliance. Weekly cart audits will continue by nurse designee and all results forwarded and reviewed by administrator of record.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation and staff interview, the facility failed to ensure a medicine cabinet, container, or compartment that is used for storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility shall be locked. EVIDENCE: At approximately 10:15AM, it was noted by the licensing inspector (LI) and staff person 1 that the B hall medication cart was unlocked. Staff person 1 found staff person 4, who was the assigned registered medication aide (RMA) for the cart, in a resident?s room providing care.
Plan of Correction:	? Employment with Carriage Hill Retirement for staff #4 was terminated on 7/25/24. ? Mandatory staff meeting for all RMAs conducted on 8/12-8/13/24. Violation Notice from 7/25/24 site visit was reviewed. Agenda also included review of compliance plan dated 10/10/23 that outlines consequences with deficient practices with medication management standards. ? 4-hourvirtual training conducted on 8/8/24 by contracted pharmacy nurse. Agenda inclusive of medication management standards. Attached signature sheet for RMAs in attendance. ? Ongoing weekly cart audits continue by nurse designee and results forwarded to administrator of record for review. All staff trained to notify a supervisor if any medication carts noted to be unlocked.
Standard #:	22VAC40-73-660-A-3
Description:	Based on observation and staff interview, the facility failed to ensure when a medicine cabinet, container, or compartment that is used for storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility, the individual responsible for medication administration shall keep the keys to the storage area on his person. EVIDENCE: At approximately 10:15AM, it was noted by the licensing inspector (LI) and staff person 1 that the B hall medication cart had the keys to the cart in the lock of the medication cart. Staff person 1 found staff person 4, who was the assigned registered medication aide (RMA) for the cart, in a resident?s room providing care.
Plan of Correction:	? Employment with Carriage Hill Retirement for staff #4 was terminated on 7/25/24. ? Mandatory staff meeting for all RMAs conducted on 8/12-8/13/24. Violation Notice from 7/25/24 site visit was reviewed. Agenda also included review of compliance plan dated 10/10/23 that outlines consequences with deficient practices with medication management standards. ? 4-hourvirtual training conducted on 8/8/24 by contracted pharmacy nurse. Agenda inclusive of medication management standards. Attached signature sheet for RMAs in attendance. ? Ongoing weekly cart audits continue by nurse designee and results forwarded to administrator of record for review. All staff trained to notify a supervisor if any medication carts noted to be unlocked.
Standard #:	22VAC40-73-660-B
Description:	Based on observation during a tour of the building, resident interview and medication cart audit, the facility failed to ensure a resident may be permitted to keep his own medication in an out-of-sight place in his room if the UAI (uniform assessment instrument) has indicated that the resident is capable of self-administering medication. EVIDENCE: 1. The UAI for resident 1, dated 06/04/2024, indicates that the resident requires their medication to be administered/monitored by lay person ? registered medication aide (RMA) or licensed practical nurse (LPN). In addition, the resident?s report of physical examination, dated 05/24/2024, indicates that the resident is not capable of self-administering their medication. 2. The licensing inspector (LI) and staff person 1 noted that resident 1 had a container of one-a-day multi vitamins in his room located on a table. Staff person 1 interviewed resident 1 about the vitamins and the resident stated that the vitamins are his and he takes one tablet daily. The record for resident 1 does not contain a physician?s order that the resident can self-administer the aforementioned medication.
Plan of Correction:	? Container of one-a- day multivitamin removed from resident's room on 7/25/24. Staff explained rationale to resident #1 and he voiced understanding of regulation. Physician notified and clarification order received for staff administration and storage of all medications including over the counters. ? Mandatory all staff meeting conducted on 8/12-8/13/24. Agenda included review of violation notice from 7/25/24 inspection. ? 4-hour virtual training conducted on 8/8/24 by contracted pharmacy nurse. Attached signature sheet for RMAs in attendance. Agenda inclusive of medication management standards. ? Environmental Rounds inclusive of room inspections for medications continue no less than weekly. Findings reported to administrator and/or designee.
Standard #:	22VAC40-73-680-B
Description:	Based on observation during a tour of the building, resident record review, resident interview, and staff interview, the facility failed to ensure medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. EVIDENCE: 1. At approximately 10:01AM, resident 1 was present in his room and upon the licensing inspector (LI) entering the resident?s room, the LI observed a small, clear plastic cup of medications sitting on the bedside table in resident 1?s room. Resident 1 informed the LI that the medications were his morning medications and that a staff person had left the medications for him to take that morning in the small, clear plastic cup. The medications were also observed and noted by staff persons 1, 2 and 3. 2. Staff person 1 completed an audit of the medications in the small, clear plastic cup and noted that the pills in the cup were the resident?s prescribed 8:00AM medications: atorvastatin 10MG, citalopram HBR 40MG, donepezil HCL 10MG, losartan potassium 50MG, and omeprazole DR 40MG. Staff person 1 stated that staff person 4 was the registered medication aide (RMA) who took the resident?s medications to his room and did not ensure that the resident had taken his medications. 3. The uniform assessment instrument (UAI) for resident 1, dated 06/04/2024, indicates that the resident requires their medication to be administered/monitored by lay person ? registered medication aide (RMA) or licensed practical nurse (LPN). In addition, the resident?s individualized service plan (ISP) for resident 1 indicates that the resident?s medications are administered by a lay person: registered medication aide (RMA) and an RMA or nurse will administer the resident?s medications per physician orders to the resident and will ensure all medications were taken and swallowed before exiting the room.
Plan of Correction:	? Employment with Carriage Hill Retirement for staff #4 was terminated on 7/25/24. ? Mandatory staff meeting for all RMAs conducted on 8/12-8/13/24. Violation Notice from 7/25/24 site visit was reviewed. Agenda also included review of compliance plan dated 10/10/23 that outlines consequences with deficient practices with medication management standards. ? 4-hour virtual training conducted on 8/8/24 by contracted pharmacy nurse. Agenda inclusive of medication management standards. Attached signature sheet for RMAs in attendance. ? Mandatory all staff meeting on 8/13/24. Agenda inclusive of violation related to medications sitting unattended at resident's bedside. All departments aware to remove any unattended medications in resident's room; deliver to nurse supervisor on duty and report to administrator in real time.