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: Sept. 2, 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:

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection (inspection was also performed in conjunction with local adult protective services): 09/02/2022 1:00PM until 2:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 08/18/2022 regarding allegations in the areas of: admission, retention and discharge of residents and resident care and related services. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-660-A-1
Complaint related:	No
Description:	Based on observation, the facility failed to ensure that when medications and dietary supplements are administered by the facility, the medicine container that is used for storage of medications and dietary supplements prescribed for residents was locked. EVIDENCE: During on-site inspection on 09/02/2022 at approximately 1:01PM, the licensing inspector (LI) and Collateral 1 observed an unlocked medication cart located in the facility?s assisted living building in the dining room and no medication staff were observed near the cart. While the LI and Collateral 1 were standing near the unlocked medication cart, staff 1 walked into the dining room and stated that she was the staff who left the medication cart unlocked and unattended.
Plan of Correction:	Staff 1 written up and given a verbal warning and education about medication carts being locked and closed. Will be monitoring medication carts twice a week.
Standard #:	22VAC40-73-680-B
Complaint related:	No
Description:	Based on observation, the facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label attached, until administered to a resident. EVIDENCE: During on-site inspection on 09/02/2022 at approximately 1:01PM, the licensing inspector (LI) observed a white, paper pill cup sitting on top of a medication cart located in the facility?s assisted living building in the dining room with two pills (one white and oblong and one white and round). Staff 1 stated the two pills were for resident 2.
Plan of Correction:	Staff 1 written up and given a verbal warning and education for leaving 2 pills unsupervised on top of the medication cart. Will be monitoring twice a week.