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 and Feb. 9, 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 11:00AM until 1:00PM and 02/09/2024 8:30AM until 10:15AM and 12:00PM until 12:10PM 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 12/22/2023 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 #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on collateral documentation, resident record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1 contains a facility staff note, dated 08/30/2023 at 3:58PM, that indicates the resident was admitted to the facility on this date. 2. The record for the resident contains a physician?s order, dated 08/29/2023, for Hydrochlorothiazide 25MG oral tablet give one tablet by mouth one time a day for HTN. 3. The August, September, and October 2023 medication administration records (MARs) from 08/31/2023 through 10/25/2023 indicate that the resident was administered one Hydrochlorothiazide 25MG tablet daily at 9:00AM for a total of 56 tablets; however, documentation from Collateral 1 indicates that 24 tablets of Hydrochlorothiazide 25MG was delivered to the facility on 08/29/2023 and 30 tablets of Hydrochlorothiazide 25MG was delivered to the facility on 09/23/2023 for a total of 54 tablets therefore the resident would have been administered only 54 tablets from 08/31/2023 through 10/25/2023. The medication was not delivered to the facility again until 10/26/2023 in which 28 tablets were signed for by staff person 1 at 2:31AM on 10/26/2023. 4. Documentation from Collateral 2?s representative, dated 08/30/2023 at 1:52PM, states that the resident was discharged from Collateral 2 on this date and the only medication that the resident left Collateral 2 with were two Klonopin.
Plan of Correction:	The following is the Plan of Correction for Carriage Hill Retirement regarding the Statement of Deficiencies date 01/29/2024 and 02/09/2024 received on 02/23/2024. 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, it 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. 22VAC40-73-680-D . Administration of medications and related provisions ? As indicated by the MAR , the medication was signed off as given on 10/24 and 10/25. Blood Pressures were obtained daily. There were no fluctuation of blood pressure reading to indicate that the Hydrochlorothiazide was not given. Attachment # 1 is a letter from resident?s Physician Assistant at facility. She is the Chief Operating Officer at Premier Geriatric Solutions PLLC. Moving forward all medications that are either brought into the building on admission or sent with resident/POA on discharge will be logged and filed in resident?s record. See attachment #2. ? All RMA?s,LPN?s will be in serviced regarding the completion of medication inventory sheet by 03/31/2024.