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: July 11, 2024 and July 25, 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: 07/11/2024 10:00AM until 11:00AM and 07/25/2024 9:30AM until 1:30PM 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 07/10/2024 regarding allegations in the area of: resident care and related services Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 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 #:	22VAC40-73-300-B
Complaint related:	No
Description:	Based on staff interview and observation, the facility failed to ensure a method of written communication shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. EVIDENCE: 1. The record for resident 1 contained a note that was entered on 07/10/2024 at 4:12PM by staff person 1 that indicated resident 1 had a fall during the evening on 07/09/2024 with no complaints; however, on 07/10/2024 the resident was complaining of pain in the right hip and that staff person 1 contacted a physician in order to see if the facility should send the resident out or not to be examined. The physician responded back for the resident to not be sent out and that a mobile x-ray would be coming to the facility to exam the resident. 2. The record for resident 1 contained a note that was entered on 07/10/2024 at 4:21PM by staff person 1 that indicated the note was a late entry for 07/09/2024 1:00PM that resident 1 was found on the floor in another resident?s room and that another resident had pushed resident 1. 3. Interview with staff person 3 on 07/11/2024 indicated that on 07/09/2024 resident 1 was pushed by resident 2 to the floor after lunch in the common area. The licensing inspector (LI) requested to see the facility?s method of written communication that is used to keep all direct care staff on all shifts informed about complaints and incidents and staff person 3 showed the LI a binder that is kept in the facility?s locked medication cart. The binder contained documents titled ?Charting Schedule? that included five entries about four residents that had had falls and one resident on a leave of absence at the hospital; however, the document did not include documentation about resident 1 and resident 2?s incident that occurred on 07/09/2024.
Plan of Correction:	? Mandatory all staff meeting conducted on 8/12-8/13/24. Agenda included review of violation notice from 7/11 and 7/25/24 complaint inspection. ? Staff communication book in memory care unit relocated from locked medication cart to centralized nurses station. ? All nursing staff trained on significance of entries in communication book to include all changes in condition, variances in typical routine and grievances. Staff to reference communication book during shift change. ? Administrator or designee to reference communication book no less than weekly to ensure all areas of concern have been managed from date of onset to resolution of situation.