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: Dec. 29, 2020

Complaint Related: Yes

Areas Reviewed:

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

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 12/29/2020 and concluded on 2/5/2021. A complaint was received by the department regarding allegations in the areas of resident care and related services and building and grounds. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued.

Violations:

Standard #:	22VAC40-73-870-A
Complaint related:	Yes
Description:	Based on documentation review and interviews, the facility failed to keep the interior of the building clean. EVIDENCE: 1. On 12/24/2020 the local emergency management services (EMS) responded to the facility for reports of resident 1 not feeling well. Interviews with EMS personnel expressed that urine was observed on the floor in resident 1's room, that the floor was very sticky and the bathroom toilet and floor were dirty. Documentation in the emergency room notes dated 12/24/2020 states that EMS found resident 1's room in disarray upon arrival.
Plan of Correction:	1. Resident room was cleaned, picked up and repaired to appropriate standards. 2. New staff were hired in the housekeeping department to assume duties of ensuring appropriate cleanliness of resident rooms. Cleaning protocols and maintaining appropriate room standards for residents are a part of their standard job duties. Housekeeping schedules and duties have assumed roles that were previously filled by nursing staff, and housekeeping personnel are focused on maintaining appropriate infection control, and environment cleanliness. 3. Our Director of Nursing is monitoring the timeliness of patient care and is simultaneously checking resident rooms at random to ensure proper order and infection control is maintained in their personal environments ongoing. 4. Administrator is overseeing the operations of the housekeeping department and is spot checking rooms at random daily to ensure these measures are being reviewed and maintained.