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. 12, 2021 and Nov. 30, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-80 COMPLAINT INVESTIGATION.

Comments:

The licensing inspector (LI) for Carriage Hill Retirement conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 10/12/2021. The LI reviewed documentation submitted by the facility and additional documentation provided by the Administrator to the LI on 11/30/2021 regarding allegations of resident care and related services and buildings and grounds. Based on the preponderance of evidence, one of the allegations is valid regarding buildings and grounds. Other violations cited can be found on the violation notice. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 589-5216.

Violations:

Standard #:	22VAC40-73-470-A
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure that, either directly or indirectly, that the health care service needs of residents were met by assisting residents in making appropriate arrangements for health care services. EVIDENCE: 1. The record for resident 1 contained a progress note from Collateral 1, dated 04/09/2021, that stated, ?I had also ordered podiatric consultation. It is not clear to me whether he has yet seen the podiatrist but he does have a follow-up appointment in the next couple of weeks.? Collateral 1 also stated in the same progress note ?He is to keep his appointment with podiatrist.? 2. Facility staff progress notes for resident 1 stated the following: ?04/09/2021 ? Resident has an appointment to Podiatry in Bedford to see (doctor) on 4-14-21 @ 2:00 p.m.?; ?04/14/2021 ? Transportation has a vehicle down and can?t transport resident today. His new appointment to Podiatry is 5-18-21 @9:00 A.M.?. The record for the resident did not contain information that the resident went to either of the scheduled podiatry appointments on 04/14/2021 or 05/18/2021. Interview with staff 1 confirmed that the resident did not go to the scheduled podiatry appointment on 04/14/2021 and also the resident did not go to the scheduled podiatry appointment on 05/18/2021.
Plan of Correction:	Resident was scheduled with an external transportation company for his appointments. The external transportation company failed to have vehicles that were in appropriate working order to service the resident twice. Our company does not have transportation services or a driver to accommodate individual resident appointments. Carriage Hill has created a list of alternative transportation services that can potentially assist residents in the event their primary transportation services are unavailable. Our staff will review resident appointments and attempt to ensure they have transportation. If a resident needs assistance with additional transportation options, staff will consult Administrator for assistance and the team will work to schedule transportation to the best of their ability.
Standard #:	22VAC40-73-870-A
Complaint related:	Yes
Description:	Based on document review, the facility failed to ensure that the interior of all buildings were kept clean. EVIDENCE: 1. Documentation in the record for resident 1 by Collateral 2, dated 09/06/2021, stated the following: "PT is found in his room, wheeling himself out of bathroom, DSG intact to left foot and PT has a R AKA.There is a strong urine odor noted in the room and the floor is sticky as this writer makes her way to a chair.". 2. A photograph, provided by Collateral 3, dated 09/30/2021 at 12:51PM, showed multiple marks of a brown substance located on the wall that the resident's bed is beside. See (ALF11041416 09-30-2021 P1) attached.
Plan of Correction:	Resident room was cleaned per regular cleaning schedule on 9/6/2021. The room was not reported by other staff, or individuals to have a urine odor, or a sticky floor. The room was renovated and repainted on 10/11/2021.