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: April 28, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION.

Comments:

The licensing inspector (LI) for Carriage Hill Retirement, under the supervision of the licensing administrator (LA) and in conjunction with another LI, conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 04/28/2022. The LIs and the LA reviewed one full resident record pertaining to an allegation that the resident needed a higher level of care, a partial record for one resident pertaining to an allegation of a prohibited condition, three residents? accounting information pertaining to allegations that these residents are not receiving their funds, one previous staff record pertaining to an allegation that one staff was hired that should not have been due to having a criminal record and one LI observed an activity being conducted by staff in regards to an allegation that activities are not being done at the facility. Findings were reviewed with facility staff during the inspection. A preliminary exit interview was conducted with the Administrator, the Director of Nursing and the Regional Director on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. A final exit interview was conducted with the Administrator via phone on 04/29/2022. The information gathered during the investigation does not support the allegation, so the complaint is determined to be ?not valid?; however, please review the violation notice to see violations that were cited as a result of the complaint inspection. 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 #:	22VAC40-73-325-C
Complaint related:	No
Description:	Based on resident record review, the facility failed to show documentation of an analysis of the circumstances of a fall and interventions that were initiated to prevent or reduce risk of subsequent falls after a resident has a fall. EVIDENCE: The record for resident 1 contained two ?Falls Risk Rating? documents, completed by staff 2, due to the resident having a fall on 02/06/2022 and on 03/23/2022; however, both documents did not show documentation of an analysis of the circumstances of the falls or interventions that were initiated to prevent or reduce risk of subsequent falls.
Plan of Correction:	Appropriate procedures for falls were reviewed with our healthcare team. DON was educated on appropriate documentation and oversight of resident falls as well as appropriate reporting requirements. Fall interventions were reviewed with the team as well. Moving forward, our DON will evaluate each fall, ensure proper documentation and that appropriate interventions are in place.
Standard #:	22VAC40-73-350-B
Complaint related:	No
Description:	Based on resident record review, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. EVIDENCE: Resident 1 was admitted to the facility on 08/19/2021; however, the record for resident 1 contained documentation that a sex offender screening was not completed for the resident until 08/20/2021.
Plan of Correction:	Our Regional Marketing Director as well as Administrator, and consultants reviewed the appropriate documentation that is to be completed and the appropriate time frames for which it should be completed with our admissions team. Our Regional Marketing Representative is working with our Admissions team to ensure ongoing compliance with admission documents. New admissions paperwork is being audited by our internal team prior to admission to ensure we are compliant with applicable paperwork needed.
Standard #:	22VAC40-73-650-C
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure physician?s or other prescriber?s orders were reviewed and signed by a physician or other prescriber within 14 days. EVIDENCE: The record for resident 1 contained the following document dated 03/29/2022: ?Physician orders ? Flagyl 250mg tablet. Crush and apply to R (right) thigh wound twice weekly per Hospice SN.? The document did not contain a signature of a physician or other prescriber and this was also noted by staff 2 during the on-site inspection.
Plan of Correction:	The appropriate signature was obtained on the resident order. All physician orders will contain appropriate documentation to ensure that they are complete. Our healthcare team is auditing charts to ensure full compliance with resident orders. Our DON will oversee physician orders, and documentation in the residents chart to ensure orders are complete.
Standard #:	22VAC40-73-700-1
Complaint related:	No
Description:	Based on resident record review, the facility failed to have a valid physician?s or other prescriber?s order that includes the oxygen source such as compressed gas or concentrators. EVIDENCE: The record for resident 1 contained a physician?s order, dated 01/23/2022, for oxygen; however, the order did not contain the oxygen source.
Plan of Correction:	The oxygen source was clarified on the physician?s order. Our DON is reviewing physician orders, and overseeing the documentation of them, to ensure the residents chart and all order are complete. Our healthcare team is auditing charts ongoing to ensure full compliance with residents orders.