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: April 19, 2024 and April 22, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 BUILDINGS AND GROUNDS 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: 04/19/2024 8:35AM until 10:30AM and 04/22/2024 2:45PM until 4:05PM 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 04/17/2024 regarding allegations in the area of: buildings and grounds 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 #:	22VAC40-73-930-A
Complaint related:	No
Description:	Based on observation, the facility failed to ensure to have a signaling device that is easily accessible to the resident in his bedroom or in a connecting bathroom that alerts the direct care staff that the resident needs assistance. EVIDENCE: During on-site inspection on 04/19/2024, it was noted by the licensing inspector (LI) and staff person 1 that resident 1?s bedroom did not contain a functioning signaling device that would allow the resident to pull a cord or push a button if the resident needed assistance. The white push button located on the Aiphone wall panel next to the resident?s bed did not send out an audible alert when the button was pushed, the hallway light above the resident?s door did not light up, and there was no indicator light on the Aiphone system box at the nurses? station to indicate that the signaling device had been activated in the resident?s bedroom. In addition, when the black signaling device button was pushed in the resident?s bathroom located beside the resident?s toilet, there was no audible sound, the hallway light above the resident?s door did not light up, and there was no indicator light on the Aiphone system box at the nurses? station that the signaling device had been activated in the resident?s bathroom. This was also noted by staff person 1.
Plan of Correction:	Resident is in memory care and does not have the cognition to use the call light. As guide lined in 930 section D, it is care planned that rounds are done every 2 hours due to the residents' inability to activate call light system. Wellness checks are documented on EMAR system and retained as part of the resident's permanent record. Resident was immediately relocated to room E15, which has a fully functional call light system. Room E20 will remain unoccupied until call system in bedroom and bathroom are completely functional. Safety checks of call lights in MC will be completed no less than monthly by Administrator or Designee. Results will be logged on Emergency System audit tool. Attached is the form for Audit.