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 24, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 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 11:00AM until 2:00PM and 07/24/2024 3:00PM until 4:00PM 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 07/09/2024 regarding allegations in the areas of: personnel and resident care & related services Number of residents present at the facility at the beginning of the inspection: 60 Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 6 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation 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 #:	22VAC40-73-130-A
Complaint related:	No
Description:	Based on documentation review, resident record review and staff interview, all staff who are mandated reporters under ? 63.2-1606 of the Code of Virginia shall report suspected abuse, neglect, or exploitation of residents in accordance with that section. EVIDENCE: 1. The licensing inspector (LI) received a complaint on 07/09/2024 reporting a concern of physical abuse against resident 1. The complaint stated that during the first week of June, resident 1 had an incident during a shower, the resident gets a shower every Tuesday, and got a black eye. The complaint stated that resident 1 stated staff person 1 gave her a shower and that staff person 1 hit her in the eye and staff person 1 was then moved to another department; however, on 07/09/2024, staff person 1 was giving the resident a shower again. 2. During on-site inspection on 07/11/2024, staff person 2 provided the LI and Collateral 1 a letter, dated 07/09/2024, that states staff person 2 spoke with staff person 1 on 06/11/2024 during the morning about the alleged incident with the resident. Staff person 2 informed staff person 1 at that time Collateral 2 had voiced some concerns and there was an open investigation about a bruise on resident 1?s face from a shower involving staff person 1. Staff person 2 asked staff person 1 not to care for the resident until the investigation was over. On 07/09/2024, Collateral 2 came to the facility and was upset that staff person 1 had given resident 1 a shower on this day. Staff person 2 spoke with staff person 1 and staff person 1 stated that she had been told the investigation was over and she was training a new employee and thought she was able to go into resident 1?s room again. Staff person 2 informed staff person 1 that at this time Collateral 2 does not want her to care for the resident and staff person 1 voiced understanding. Staff person 1 also signed a statement along with staff persons 2 and 3, dated 07/09/2024, that she will not provide care to resident 1 per Collateral 2?s request. 3. The facility?s communication log, dated 06/17/1024, contains a written statement by staff person 3 that states the resident?s power of attorney came in to see the resident and seen ?bruise on eye? and a staff progress note by staff person 3, dated 06/17/2024 at 10:08AM, that the resident?s daughter came in to see staff person 3 on 06/17/2024 and stated to staff person 3 that resident 1 had a bruise on her left eye. Staff person 3 stated that it was not reported to them from resident 1 nor staff person 4 who was also present for the conversation with staff person 3 and the resident?s daughter. Staff person 3 stated that the resident?s daughter was told that the facility will look into the matter by staff person 4. 4. During an interview with staff persons 2 and 4 on 07/11/2024, it was revealed to the LI and Collateral 1 that the aforementioned allegations of suspected abuse had not been reported by the facility to their local Adult Protective Services Agency as required by ? 63.2-1606 of the Code of Virginia.
Plan of Correction:	This occurred with the community?s past management. We will implement to following interaction: Inservice of Abuse Policy with mangers and staff Inservice of Injury of unknown origin Mandating Reporting will be covered in monthly staff meetings Note. These are the new Policies and Procedures from the new management group that started at the community August 15th, 2024.