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: May 22, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/22/2024 8:00AM until 2:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 50 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication cart audits, noon-time medication pass, breakfast and lunch meals An exit meeting will be conducted to review the inspection findings. 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-K
Description:	Based on resident record review, the facility failed to ensure the use of PRN medications is prohibited, unless the resident is capable of determining when the medication is needed, licensed health care professionals administer the PRN medications; or medication aides administer the PRN medication when the facility has obtained from the resident?s physician or other prescriber a detailed medication order and the order shall include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist. EVIDENCE: 1. The record for resident 2 contains an assessment of serious cognitive impairment, dated 04/26/2024, that states the resident has a serious cognitive impairment due to a primary psychiatric diagnosis of dementia. The resident resides in the facility?s safe, secure unit. 2. The record for the resident contains a physician?s order for lorazepam (Ativan) take 0.5ML liquid by mouth under tongue every four hours as needed for anxiety and terminal agitation. 3. The May 2024 medication administration record (MAR) for resident 2 indicates that the aforementioned PRN medication was administered to the resident by a registered medication aide (RMA) on 05/07/2024 at 10:43PM; however, the physician?s order does not include symptoms that indicate the use of the medication. This was also noted by staff person 6.
Plan of Correction:	The following is the Plan of Correction for Carriage Hill Retirement regarding the Statement of Deficiencies date 5/22/2024. This Plan of Correction is not 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 regular 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 improvements to satisfy that objective. 22VAC40-73-680-K Administration of medications and related provisions. ? The Director of Nursing corrected immediately for resident #2 while the inspector was on site. Completed 5/22/2024. ? The Director or Designee has audited all PRN orders. Corrections to be made to them if a resident is unable to voice why they need a prn to include symptoms for reason the PRN is needed. To ensure RMA can give the PRN by the symptoms listed on each order. Completed on 5/24/2024. ? To assist with ongoing compliance, the Director of Nursing or Designee will review all new admit orders upon admission and with any new orders. To ensure the PRNs are written so an RMA can administer PRN?s if a resident cannot verbalize the need for one. ? Regional Designee will conduct random audits of all new prn medication orders no less than monthly to monitor for ongoing substantial compliance.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review and staff interview, the facility failed to ensure that criminal history record reports were obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The criminal history record report for staff person 1, date of hire 06/22/2023, was not obtained until 05/22/2024. 2. The criminal history record report for staff person 3, date of hire 09/14/2023, was not available during on-site inspection. Interview with staff person 2 confirmed that this was accurate.
Plan of Correction:	The following is the Plan of Correction for Carriage Hill Retirement regarding the Statement of Deficiencies date 5/22/2024. This Plan of Correction is not 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 regulatory 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 improvements to satisfy that objective. 22VAC40-90-40-B Criminal History Record Report ? The Executive Director or designee will provide education for the Business Office Manager on Criminal History Records and Virginia regulations to be completed by 5/31/24. ? The Business Office Manager or Designee will audit all current staff records for Criminal History Records to be completed by 5/31/24. ? To assist with ongoing compliance, the Business Office Manager or Designee will audit all new staff records for Criminal History Records once a month for three months 06/2024, 07/2024 and 08/2024. ? Regional designee will conduct random audits of criminal history records (barrier crimes) for all new hires for the next three months. (6/2024, 7/2024, 8/2024)
Standard #:	22VAC40-90-40-D
Description:	Based on staff record review and document review, the facility failed to ensure that an employee has not been convicted of any of the barrier crimes when a criminal history record was requested. EVIDENCE: 1. The document ?Barrier Crimes for Licensed Assisted Living Facilities and Adult Day Care Programs?, dated October 2023, states that a licensed assisted living facility may hire an applicant convicted of one misdemeanor barrier crime not involving abuse or neglect, or any substantially similar offense under the laws of another jurisdiction, if five years have elapsed following the conviction. 2. The record for staff person 4, date of hire 08/22/2023, contained a Virginia criminal record, dated 08/22/2023, that staff person 4 was found guilty of a misdemeanor 01/08/2021. The misdemeanor is listed as a barrier crime on the document ?Barrier Crimes for Licensed Assisted Living Facilities and Adult Day Care Programs? and five years have not elapsed following the conviction.
Plan of Correction:	The following is the Plan of Correction for Carriage Hill Retirement regarding the Statement of Deficiencies date 5/22/2024. This Plan of Correction is not 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 regulatory 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-K Criminal History Record Report ? The Executive Director or designee will provide education for Business Office Manager on Criminal History Records and Barrier Crimes for Virginia regulations to be completed by 5/31/24. ? The Business Office Manager or Designee will audit all current staff records for Criminal History Records and review all for barrier crimes to be completed by 5/31/24. ? To assist with ongoing compliance, the Business Office Manager or Designee will audit all new staff records for Criminal History Records and review for any barrier crimes once a month for three months 06/2024, 07/2024 and 08/2024. ? Regional designee will conduct random audits of criminal history records (barrier crimes) for all new hires for the next three months. (6/2024, 7/2024, 8/2024)