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: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Monitoring 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. Number of residents present at the facility at the beginning of the inspection: 63 The licensing inspectors completed a tour of the physical plant that included the buildings and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication cart audits, medication passes, noon-time meal, activities. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-1140-B
Description:	Based on staff record review, the facility failed to ensure that within four months of the starting date of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairment. EVIDENCE: 1. The record for staff 1, date of hire 11/01/2022, has documentation that the employee only received 8.75 hours of training in cognitive impairments within four months of the starting date of employment. 2. The record for staff 3, date of hire 11/26/2022, has documentation that the employee only received 5 hours of training in cognitive impairments within four months of the starting date of employment.
Plan of Correction:	1. All staff will have the required training due by 06/30/2023. 2. Will ensure we are able to obtain required training from Relias for all employees once hired and afterwards. 3. An Inservice book for all staff is in place and Relias to ensure compliance with regulations. All new hires will receive the additional 10 hours upon hire. 4. BOM/ED will audit all new Employee File Audits within 45 days of hire to ensure compliance. 5. Completion Date 06/30/2023
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review, the facility failed to ensure that private pay uniform assessment instruments (UAI) were completed as required. EVIDENCE: 1. The UAI for resident 7, dated 12/18/2022, is marked that the resident is abusive/aggressive/disruptive less than weekly; however, the area for the resident?s type of inappropriate behavior is blank.
Plan of Correction:	1. 1. The UAI was corrected the day of inspection on 05/16/2023. 2. 2. All UAI?s will continue to be reviewed by the ISP/UAI Coordinator as well as DON and ED after completion. 3. 3. UAI/ISP Coordinator to conduct 3 audits monthly of ISPs for correction. 4. 4. Completion Date- 06/30/2023
Standard #:	22VAC40-73-700-2
Description:	Based on observation during a tour of the building, the facility failed to post a ?No Smoking-Oxygen in Use? sign in any room of a building where oxygen is in use. EVIDENCE: The record for resident 3 contained a physician?s order, dated 01/12/2023, for the resident to have as needed (PRN) oxygen. At approximately 1:31PM during on-site inspection, one licensing inspector (LI) noted that resident 3?s room contained an oxygen concentrator with tubing; however, there was not a ?No Smoking-Oxygen in Use? sign posted in or around the resident?s room.
Plan of Correction:	? 22VAC40-73-700-2 ? 1. Sign was placed on day of Inspection on 05/16/2023 ? 2. DON notify all home health and Hospice of the need to place sign with any oxygen being ordered for residents. ? 3. DON/ED will check monthly to ensure correct signs for oxygen are in place. ? 4. Completion Date- 06/30/2023
Standard #:	22VAC40-73-870-E
Description:	Based on observations of the facility physical plant, the facility failed to ensure that all furnishings were maintained in good repair. EVIDENCE: 1. The footboard to the bed in room 8 was noted to be loose on the day of inspection and a crack was observed in the wood of the bed frame near the screws.
Plan of Correction:	1. The bed was replaced on the day of inspection. 2. All beds will be visualized and inspected to comply by housekeeping and maintenance by 06/30/2023. 3. Completion Date ? 06/30/2023
Standard #:	22VAC40-73-950-E
Description:	Based on document review and staff interview, the facility failed to ensure there was a semi-annual review on its emergency preparedness and response plan for all residents. EVIDENCE: 1. The record for resident 10 contained documentation that the resident has not had a review on the facility?s emergency preparedness and response plan since 08/11/2022. 2. The record for resident 11 contained documentation that the resident has not had a review on the facility?s emergency preparedness and response plan since 07/31/2022. 3. The record for resident 12 contained documentation that the resident has not had a review on the facility?s emergency preparedness and response plan since 06/26/2022.
Plan of Correction:	? 1. All residents /Families will have facility emergency preparedness response plan reviewed to ensure compliance moving forward it will be due for all residents in June and December it will be sent via email and in the mail. ? 2.All residents and families will receive an updated facility emergency preparedness response via email and mail by June 30, 2023 ? 3.Completion Date- 06/30/2023