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: Aug. 9, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 08/09/2023 8:45AM until 1:15PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 #:	22VAC40-73-680-D
Description:	Based on resident record review the facility failed to ensure medications were administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1 contains a physician?s order, dated 07/06/2023, for Humalog insulin inject four units three times daily and the medication is to be held if the resident?s blood sugar is less than 150. 2. The 07/21/2023 through 08/09/2023 medication administration record (MAR) for resident 1 indicates that the resident was administered Humalog insulin at 12:00PM and 8:00PM on 07/23/2023; however, there is no documentation of what the resident?s blood sugar was during these times. In addition, the resident?s blood sugar was documented as 143 at 12:00PM on 07/30/2023 and documented as 6 at 8:00PM on 08/08/2023; however, the MAR indicates that Humalog insulin was administered to the resident. 3. This standard was previously cited on 07/15/2022, 10/20/2022 and 03/08/2023.
Plan of Correction:	Plan of Correction from Inspection August 9, 2023 - 22VAC40-73-680-D 1. Resident 1 file and med list was reviewed the day of inspection by DON/Administrator. 2. DON/Administrator completed training with all staff that administer medications regarding the violation notice, the reason for the violation, and notifying the DON for correction immediately when documentation errors occur. 3. All Staff that administer medications will complete 2 hours of training on Avoiding Common Medication Errors and Documenting Medications. 4. DON will review Medication Records for all insulin dependent diabetics monthly and will review results with Administrator and Regional Designee. 5. Completion Date- 10/20/2023