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: May 16, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 05/16/2023 8:45AM until 3:00PM 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 03/20/2023 regarding allegations in the areas of: personnel, resident care and related services and buildings and grounds. The evidence gathered during the investigation supported some, but not all of the allegations area(s) of non-compliance with standard(s) or law. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also 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 #:	22VAC40-73-860-I
Complaint related:	Yes
Description:	Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area. EVIDENCE: 1. A bottle of Prime Source Germicidal Ultra Bleach was noted sitting out on a bottom shelf at the nursing station in the facility safe, secure unit. The door to the nursing station was noted to have a sliding latch on the door but was not able to be locked. 3. This standard was previously cited on 10/20/2022, 12/08/2022, 01/17/2023 and 03/08/2023.
Plan of Correction:	? 1. Item was removed by staff on-site with inspector on 05/16/2023. ? 2. The nurses area shelfing in the safe and secure area has now been covered by maintenance and a new locking mechanism will be placed to assist in keeping this area safe. ? 3. All managers will continue to complete 3- 5 times a weekly room rounds to ensure that all rooms are in standard. All residents that have continued to have non-compliance issues will be issued a 30-day notice as well as it was discussed again during resident council meeting. We have 2 residents that continue to have 30-day notices after 6 months of the first issued notice due to non-compliance with no assistance in finding new placement for the residents. ? 4.Completion Date -06/30/2023 and when assistance is received for placement for residents that continue having non-compliance issues. We continue to ask for assistance from all our local DSS and other agencies to ensure correct placement can happen.