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 and March 2, 2022

Complaint Related: Yes

Areas Reviewed:

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

Comments:

The licensing inspector (LI) conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 02/28/2022 in conjunction with the local long-term care ombudsman. The LI interviewed the resident the complaint was regarding, reviewed documentation for the resident, toured the resident's room, and conducted one staff interview on 02/28/2022 and one staff interview via phone on 03/02/2022 relating to allegations of the resident's diet not being served correctly, not receiving medication and the cleanliness of the resident's room. The LI held a preliminary exit interview with the administrator on 02/28/2022 while the LI was at the facility and an exit interview was also held with the administrator via phone call on 03/04/2022 where the violations were discussed and an opportunity was given to ask questions. The information gathered during the investigation supports one of the allegations. 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 #:	22VAC40-73-650-A
Complaint related:	No
Description:	Based on resident record review and resident and staff interviews, the facility failed to ensure that medications that were started by the facility had a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications. EVIDENCE: 1. During an interview with resident 1, resident 1 informed the licensing inspector (LI) and Collateral 1 that she had been given Tylenol by staff 1 on 02/26/2022 at 2:00PM. The record for resident 1 did not contain a valid order from a physician or other prescriber for the resident to have Tylenol. 2. During interview with staff 1, staff 1 confirmed to the LI that she did administer resident 1 Tylenol on 02/26/2022 at 2:00PM, that the Tylenol was staff 1?s personal Tylenol and confirmed that the resident does not have a valid order from a physician or other prescriber for Tylenol. LI asked staff 1 if this was documented on a medication administrator record (MAR) for resident 1 and staff 1 stated it was not documented on a MAR.
Plan of Correction:	A Tylenol PRN order was established for Resident 1. Staff 1 was counseled on the need to have and if pending, wait for a valid order from a physician or other prescriber before administering any medication including over the counter medications.
Standard #:	22VAC40-73-870-E
Complaint related:	No
Description:	Based on observation, the facility failed to ensure all furnishings, fixtures, and equipment, including showers, were kept clean. EVIDENCE: During on-site inspection on 02/28/2022, resident 1 informed the licensing inspector (LI) and Collateral 1 that there was a coating of dust on the top of the walk-in shower in the bathroom of resident 1?s room. The LI, along with Collateral 1 and staff 3, observed that there was a coating of dust along the top of the shower resident 1?s room.
Plan of Correction:	Resident 1?s bathroom has been deep cleaned. All resident rooms are on a routine deep cleaning schedule that rotates several times throughout the week. All rooms are cleaned daily, and are rotated on a deep clean schedule daily.