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: Jan. 29, 2024

Complaint Related: Yes

Areas Reviewed:

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

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/29/2024 12:06PM until 12:45PM 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 01/05/2024 regarding allegations in the area of: resident care and related services An exit meeting will be conducted to review the inspection findings. 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 #:	22VAC40-73-70-A
Complaint related:	No
Description:	Based on resident record review and staff interview, the facility failed to ensure to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. EVIDENCE: 1. The record for resident 1 contained facility staff notes, dated 12/04/2023 at 12:02AM, that the resident was sent to the emergency room due to a fall in the main lobby in which she hit her face on a glass top table and a cut on her nose was noted. 2. Hospital discharge documentation, dated 12/04/2023 at 4:21AM, indicated that the resident was diagnosed with a nasal bone fracture, injury of tendon of biceps and laceration of nose and that the laceration on the resident?s face was closed with skin glue. 3. As of on-site inspection on 01/29/2024, the aforementioned incident involving resident 1 had not been reported to the regional licensing office. Staff persons 1 and 2 confirmed that this is accurate.
Plan of Correction:	The following is the Plan of Correction for Carriage Hill Retirement regarding the Statement of Deficiencies date 01/29/2024 but received 02/09/2024. This Plan of Correction is not be constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, ii is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 22VAC40-73-70. Incident reports. All reportable incidents will be reported directly to the Director of Nursing or Designee. Nursing Director of Designee will notify Administrator and Regional Designees Director of Nursing or Designee will complete and submit reportable events within 24 hours of any major incident per regulation. Administrator and Regional Designees will be CC'd on all reportable events email.