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: Feb. 28, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-80 COMPLAINT INVESTIGATION.

Comments:

The licensing inspector (LI) for Carriage Hill Retirement conducted an unannounced complaint inspection in conjunction with local adult protective services in response to a complaint that was received by the licensing office on 02/28/2022. The LI and adult protective services reviewed documentation and conducted interviews regarding allegations of a resident to resident altercation and if one resident was receiving appropriate care and if the other resident was safe in the facility. The Administrator had also informed the LI of two additional resident to resident altercations. The LI and the Administrator had a discussion regarding standard 1080-A. The LI held an exit interview via phone with the Administrator on 03/09/2022 where an opportunity was given to ask questions and review the violation(s). The information gathered during the investigation determined one of the allegations to be valid and violations can be found on the violation notice. Please sign, date, and return this notice 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 #:	22VAC40-73-1080-A
Complaint related:	No
Description:	Based on resident record review and collateral interview, the facility failed to ensure that a resident had a serious cognitive impairment due to a primary psychiatric diagnosis of dementia prior to being admitted to the safe, secure environment as defined in 22VAC40-73-10. EVIDENCE: 1. According to the State Board of Social Services Standards for Licensing Assisted Living Facilities in Virginia, a safe, secure environment is defined as a self-contained special care unit for residents with serious cognitive impairments due to primary psychiatric diagnosis of dementia who cannot recognize danger or protect their own safety and welfare. 2. Resident 1 was admitted to the facility?s safe, secure unit (special care unit) on 01/28/2022. 3. The report of resident physical examination, dated 12/27/2021, and the assessment of serious cognitive impairment, dated 01/26/2022, for resident 1 do not contain information that the resident has a diagnosis of dementia. 4. Interview with Collateral 1 via phone on 03/03/2022 confirmed that resident 1 does not have a diagnosis of dementia. 5. Considering the aforementioned information, resident 1 was not appropriate to be admitted to the facility's safe, secure unit due to not having a primary diagnosis of dementia.
Plan of Correction:	Facility has updated its admission requirement into the secured unit environment or memory care unit to include primary psychiatric diagnosis of dementia. Potential resident with a serious cognitive impairment who cannot recognize danger or take of themselves due to TBI or other impairments without a diagnosis of dementia will not be admitted.