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: Sept. 9, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/09/2022 12:20PM through 1:35PM 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 09/09/2022 regarding allegations in the areas of: administration and administrative services and buildings and grounds. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also 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 #:	22VAC40-73-40-A
Complaint related:	Yes
Description:	Based on observation and staff interview, the licensee failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department. EVIDENCE: Interview with staff 1 during on-site complaint inspection on 09/09/2022 revealed that he and his wife had been staying in room E29 located in the facility?s safe, secure unit. Staff 1 informed the licensing inspector, and the licensing inspector received confirmation from staff 2, that staff 1 had been informed by a corporate staff member that it was okay that they stay at the facility. Staff 1?s wife is not an employee of the facility. Interview with staff 2 on 09/09/2022 revealed that staff 1 and his wife had been staying in room E29 since 09/06/2022.
Plan of Correction:	Staff 1 since then has been terminated.
Standard #:	22VAC40-73-870-A
Complaint related:	Yes
Description:	Based on observation, the facility failed to ensure the interior of the building was maintained in good repair and kept clean. EVIDENCE: 1. The ceiling in room E29 contained a large brown stain to the left of the entry door into the room. 2. The floor around the toilet in resident 1?s bathroom contained a dark colored stain and was wet. This was observed by staff 2. 3. On the floor in front of resident 2?s bed there was a pile of food crumbs and a plastic white fork. This was observed by staff 2. 4. A bed side rolling table located in resident 3?s room contained a pair of black socks, a pair of pants and white napkins. When the licensing inspector got close to the items on the table, multiple small gnats started flying from the items which was also observed by staff 2.
Plan of Correction:	The ceiling in room E29 is currently being repaired and fixed by the maintenance director. The floor around the toilet in resident l's bathroom has been cleaned and fixed by housekeeping and maintenance and will be cleaned every day by housekeeping. The floor by resident 2's bed was cleaned up by housekeeping, we do a room sweep twice a week to maintain cleanliness. Resident 3's room was cleaned and sanitized and will be added one of the rooms they deep clean every day they come in.